Qua
Maine Revenue Services
Mahogany Quahog Dealer’s
00
*1127000*
Registration No.
Period Begin
Due Date
Period End
1. Entity Information
2.
OUT OF BUSINESS?
Date closed:
3. OWNERSHIP OR NAME CHANGE?
Date
Explanation
4. SOLD? Date
ADDRESS CHANGE?: Check here and make the appropriate changes to the preprinted address.
Do Not Use Red Ink!
Bushels
Total bushels purchased during month for which this report is made
1.
, ,
, ,
.
Total Due
Tax at $1.20 per bushel
2.
Credits
Credit Carry Forward From Prior Period
3.
, ,
.
Amount Due Line 2 minus line 3. Use line 5 if the result is a credit amount.
4.
, ,
.
If Line 2 minus line 3 is a credit amount, enter the amount to the right. If you wish a refund
Credit
Due
, ,
.
rather than a carry forward to the next period, check here.
5.
With Payment Mail To:
Maine Revenue Service, P. O. Box 1065, Augusta, ME 04332-1065
If No Payment or Claiming Credit Mail To: Maine Revenue Service, P. O. Box 1064, Augusta, ME 04332-1064
Title
Date
Signature
Phone #
For assistance in completing this form, call (207) 624-9609
MQ-3 Revised 09/2011