Combined Registration Application For State Of Delaware Business License And/or Withholding Agent

Combined Registration Application For State Of Delaware Business License And/or Withholding Agent - 2000 Page 3

STATE OF DELAWARE

Mail This Copy With Remittance

INITIAL

Payable To

MONTHLY

Delaware Division of Revenue

P.O. Box 8995

EMPLOYER'S REPORT OF

Wilmington, DE 19899-8995

089 OR 090

DO NOT WRITE OR STAPLE IN THIS AREA

DELAWARE TAX WITHHELD

Employer Identification Number

FOR OFFICE USE ONLY

Social Security Number

Suffix

BUSINESS NAME AND ADDRESS

PAYMENT DUE DATE 15 days after end of month

PAYMENT FOR PERIOD

FROM

Month

Day

Year

Month

Day

Year

MAILING ADDRESS IF DIFFERENT

1. AMOUNT WITHHELD AND DUE FOR PERIOD

2. AMOUNT REMITTED

AUTHORIZED SIGNATURE (I DECLARE UNDER PENALTIES OF PERJURY THAT THIS IS A TRUE, CORRECT AND COMPLETE RETURN.)

DATE

TELEPHONE NUMBER

STATE OF DELAWARE

INITIAL

Mail This Copy With Remittance

QUARTERLY

Payable To

Delaware Division of Revenue

GROSS RECEIPTS

P.O. Box 2340

Wilmington, DE 19899-2340

TAX RETURN

028

DO NOT WRITE OR STAPLE IN THIS AREA

Employer Identification Number

FOR OFFICE USE ONLY

BUSINESS DESCRIPTION

Social Security Number

PAYMENT FOR QUARTER ENDING

PAYMENT DUE DATE

FILING PERIOD

BUSINESS NAME AND ADDRESS

Last day of first month

following the end of quarter

GROSS RECEIPTS

1. TOTAL GROSS RECEIPTS

2. LESS EXCLUSION

MAILING ADDRESS IF DIFFERENT

3. TAXABLE AMOUNT

TAX RATE

4. GROSS RECEIPTS TAX, LINE 3 X _______________ =

5. APPROVED TAX CREDITS

6. BALANCE DUE. SUBTRACT LINE 5 FROM LINE 4

AUTHORIZED SIGNATURE (I DECLARE UNDER PENALTIES OF PERJURY THAT THIS IS A TRUE, CORRECT AND COMPLETE RETURN.)

DATE

TELEPHONE NUMBER

Combined Registration Application For State Of Delaware Business License And/or Withholding Agent - 2000 Page 3

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