Form Gro 217 - Vending Machine Addendum For Decals Gross Receipts Tax
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1TENNESSEE DEPARTMENT OF REVENUE
500 DEADERICK STREET
ANDREW JACKSON STATE OFFICE BUILDING
NASHVILLE, TN 37242
VENDING MACHINE ADDENDUM FOR DECALS
GRO
GROSS RECEIPTS TAX
217
COMPLETE THIS FORM AND RETURN IT WITH YOUR REMITTANCE (TOTAL ON LINE 4) FOR EACH NON-PROFIT ORGANIZATION.
ALL QUESTIONS MUST BE ANSWERED COMPLETELY FOR YOUR REMITTANCE TO BE PROPERLY CREDITED.
1.
TAXPAYER NAME AND MAILING ADDRESS
NAME (GIVE TRADE NAME AT THIS LOCATION)
ACCOUNT NUMBER:
STREET, HIGHWAY, COMMUNITY (DO NOT USE P.O. BOX #)
CITY
COUNTY
STATE
ZIP CODE
FEIN:
2.
CHARITABLE - NON-PROFIT ORGANIZATION NAME AND MAILING ADDRESS
NAME (GIVE TRADE NAME AT THIS LOCATION)
STREET, HIGHWAY, COMMUNITY (DO NOT USE P.O. BOX #)
CITY
COUNTY
STATE
ZIP CODE
FEIN:
3. Total number of vending machines operated for the benefit of the above tax exempt organization ____________ X $1.00 $ ______
4. Total remittance enclosed (Line 3) .................................................................................
00
MAKE CHECK PAYABLE TO:
TENNESSEE DEPARTMENT
For additional information regarding this application you may call Taxpayer Services between 8:00 a.m.
OF REVENUE
500 DEADERICK STREET
and 4:30 p.m. (CT), Monday through Friday, holidays excepted. For assistance, Tennessee residents
ANDREW JACKSON STATE
can call our statewide toll free number at 1-800-342-1003. Out-of-state callers must dial (615) 253-
OFFICE BUILDING
0600.
NASHVILLE, TN 37242
Under penalties of perjury, I declare that the statements in this application are true and correct to the
best of my knowledge and belief. This application applies only to the specified business and location
listed hereon.
Authorized Signature & Title
FOR OFFICE
USE ONLY
FOR DEPARTMENT USE ONLY
RV-R0011601
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