Form Exc-Tire-01.01 - Tire Surcharge Fee Return
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1
2NEVADA DEPT OF TAXATION
TID or
TIRE SURCHARGE FEE RETURN
Account No.
FOR DEPARTMENT USE ONLY
Mail Original to:
Amount
Nevada Department of Taxation
1550 College Parkway, Rm. 115
Check #
Carson City, NV 89706
Date
Phone: (775) 684-2000
Initials
________________________
For month ending
Due on or before
Date paid
If the name or address as shown is incorrect, if the ownership or business
location has changed, or if you are out of business, notify a Nevada
Department of Taxation District Office immediately.
A RETURN MUST BE FILED EVEN IF NO FEE LIABILITY
EXISTS
1.
$
Total Tires
x $1.00 per tire =
2.
$
(
)
Less Administrative Allowance 5% (.05 x Line 1)
3.
$
2)
Net Taxes Due and Payable (Line 1 minus Line
4.
Total Penalties (SEE INSTRUCTIONS) (For periods prior to 4/1/2007 the penalty is
$
10%)
5.
$
Total Interest (SEE INSTRUCTIONS) (Rate change effective 7/1/2011 to .75% for each month)
6.
$
Plus debits as established by the Department of Taxation
7.
$
(
)
Minus credits as established by the Department of Taxation
8.
$
Total Due and Payable (Line 3 + Line 4 + Line 5 + Line 6 - Line 7)
?
$
Total Amount Remitted with Return
?
DO NOT COMBINE THIS TAX WITH ANY OTHER TAXES
MAKE CHECKS PAYABLE TO NEVADA DEPARTMENT OF TAXATION
I hereby certify that this return, including any accompanying schedules and statements, has been examined
by me and to the best of my knowledge and belief is a true, correct and complete return.
SIGNATURE
PHONE NUMBER
PRINT NAME
FEDERAL ID OR SOCIAL SECURITY NUMBER
TITLE
DATE
TIRE SURCHARGE FEE RETURN
EXC-TIRE-01.01
7/1/2011
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