Form 0405-055 - Alaska Telephone Cooperative Gross Revenue Tax Return
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1DEPARTMENT USE ONLY
Alaska
ENV
055
FSN
Telephone Cooperative Gross
Revenue Tax Return
(AS 10.25.550)
Due Date: Before the first day of March following the close of the taxable year.
Alaska Business License Number
Calendar Year
Federal EIN
Business Name
Contact Person
Mailing Address
Contact Telephone
Fax Number
City
State
Zip Code
Contact Email
(A)
(B)
TAX
Computation of Tax
Total Gross Revenue
Tax Rate
Column (A) X (B)
1. Cooperative furnishing service for less than five years
0.01
as of December 31........................................................
2. Cooperative furnishing service for five years or longer
0.02
longer as of December 31.............................................
3. Total Tax Due. Enter applicable amount here.......................................................................................................
Allocation Schedule (This section must be completed so refunds to local governments can be made in accordance with
AS 10.25.570)
City or Borough in which
Amount of Gross Revenue
Applicable Tax Rate
Amount of Tax
Gross Revenue was Earned
TOTAL
If more space is needed for additional taxing authorities, attach a separate schedule and enter the
total amount here....................................................................................................................................
TOTAL (must equal the amount of line 3 above).....................................................................................
I declare under penalty of perjury that this return, including all 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.
Taxpayer Signature
Title
Date
Department Use Only
Validation
PMD
055
Mail to: Alaska Department of Revenue, PO Box 110420, Juneau AK 99811-0420
0405-055 Rev 01/13
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Parent category: Financial