SALES                                                                                                             FILING PERIOD (Required)
                                                  CITY & COUNTY OF BROOMFIELD
                          TAX  
                                                           Sales Tax Administration Division
                         RETURN
                                                           P.O. Box 407
   Note:
            You must file this return even                 Broomfield, CO 80038-0407                                                       Returns not postmarked by 
            if line 15 is zero $                                                                                                            the due date will be late
If filing a Consolidated Return, OR advising of changes on                                      Due Date                                                                     City's License Number ( Required )
page 2, please place a LARGE "X" in box at right

                   Enter Business or Trade Name:
                                                                                            6. Excess Tax Collected
                                                                                                    (see instructions)

                                                                                            7. Sub-Total of Sales Taxes:                                                   -
  *** Important Message ***                                                                         ( Line 5 plus line 6)
Late returns will be assessed a $15 per notice penalty                                      8. Vendor Fee:                 (line 7 times 3%)
                                                                                                                                                                           -
fee for the first & second issuance of the delinquency                                          Max = $200, Enter -0- on Late Return
notice. Assessment penalty fees will be $25/notice or 
                                                                                            9. Vendor Fee:Net Broomfield City and County
15% of tax due for the 3rd, 4th and 5th notices, 6th or                                                                                                                    -
                                                                                                Sales Tax: (line 7 minus line 8)
more $50 per notice or 30% of tax due.
                                                                                           10.LodgingVendor Fee::Tax Balance due from
                                                                                           Lodging Tax Return (Attach copy of return)
1. GROSS SALES & SERVICES:                              (Round to even $)                  11. Special District Tax:              For businesses located in
   (Total receipts, before sales tax, from City &                                                                                  special district ONLY
   County activity must be reported including all                                              (a) Flatiron Improv. Dist.  (FID)
   sales, rentals, leases, & services, both taxable and 
   non- taxable)                                                                           (Taxable sales) times .01% (.0001)
1 a.      ADD - Bad Debts Collected:                                                            (b) Arista Local Improv. Dist. (ALID) 
   (which were previously deducted)                                                        (Taxable sales) times .2% (.002)
2. Adjusted Gross Sales & Services:                                                        12. Vendor Fee:  Late Filing Penalty:
                                                                                       -   
   (Line 1 plus 1a)                                                                             ( See Instructions)
3.  Exemptions:                                                                            13. Vendor Fee:  Interest:
                                                                                       -   
   (Please insert total of line 3 from page 2 )                                                 ( See Instructions)
4.  Net Taxable Sales & Services:                                                          14. Adjustments:  Adjustments:  See Instructions
                                                                                       -   
   (Line 2 minus line 3 )                                                                       ( Attach Authorization Letter)
5. Broomfield City and County                                                              15. Adjustments:  Total Due and Payable:
   Sales Tax:                                                                                   (Add Line 9 through line 13)
                                                                                                                                                                           -
   ( Line 4 multiplied by 4.15%) or (.0415)                                            -        [Minus line 14 if credit is authorized; Plus line 
          ( Continued on line 6 )                                                               14 if a debit is required]
Business Location
                                                                                                   Make Check or Money Order Payable to:          
                                                                                                       City and County of Broomfield

                                                                                                Phone:               303-464-5811          Fax:   303-410-3802
My signature affirms that I have read this return and it is true and correct to the 
best of my knowledge and is signed subject to penalties for perjury and other                   Email:               salestax@broomfield.org
criminal offenses.                                                                              Web:                 www.broomfield.org/salestax

  Signature:                                                                                                               Date:
  Title:                                         Phone:                        Fax:                                         Email:

  CITY & COUNTY OF BROOMFIELD           Sales Tax Return               Page 2

                  Line 3  (Detail)                               Exempt Sales                     (See page 3 for instructions)

  A               Non-Taxable Service or Labor:

  B               Sales to Licensed Dealers: (Must support exemption with valid Resale Number)

  C               Sales Shipped Out of the City & County of Broomfield:      

  D               Bad Debts Charged Off:   (On which tax was previously paid):

  E               Trade-ins: (Where property will be resold at taxable value)

  F               Sales of Cigarettes

  G               Exempt Sales: (Government, religious, & charitable organizations)

  H               Returned Goods:    (on which tax was previously paid)

  I               Sales of Lottery and Gasoline:

  J               Prescription Drugs, and other exempt medical transactions: 
                  Food purchased with Food Stamps or WIC Vouchers: (Does not include “Food for Home 
  K
                  Consumption” sold without stamps or vouchers)                        (See Instructions)
                  Sales of Building Materials: (Only when supported by a Building Permit, showing Local Use Tax 
  L               paid, and the permit number is shown on invoice)
M                 Miscellaneous exempt sales:  (Please explain)
                        Line 3: Total Exemptions:   (Total of Line A though Line N) 
                                                                                                                                                                                                                                                                              -
                                                                            (Carry amount to line 3 on Page 1)

SCHEDULE B:  CONSOLIDATED ACCOUNT REPORT

  This schedule is required in all cases where the vendor is reporting sales for more than one location within the City and County of Broomfield. Each location must have 
  a separate license.(Attach a separate spreadsheet if necessary)

                                                                                        Total Gross Sales 
  Account                            Business                                               For Reporting                                  Total                                                                                                                                                                    Net              
  Number                             Location Address                                                                             Period   Exemptions                                                                                                                                                               Taxable Sales
                                                                                      $                                                  $                                                                                      $                                 -
                                                                                      $                                                  $                                                                                      $                                 -
                                                                                      $                                                  $                                                                                      $                                 -

Totals:                                                                               $                                 -                $                                 -                                                    $                                 -

  ADDRESS  CHANGES:                                                                    BUSINESS STATUS CHANGES: ADDRESS  CHANGES:                                                                    BUSINESS STATUS CHANGES:   
                  
 Mailing address:   _________________________                   1) Ownership (Date, New Owner and Phone)  Mailing address:   _________________________                   1) Ownership (Date, New Owner and Phone) 
 City, State              ________________________                         ____________________________________                    City, State              ________________________                         ____________________________________                   
 Zip:                       _________________________                         ____________________________________  Zip:                       _________________________                         ____________________________________ 
 Location address: _________________________                      Location address: _________________________                     
                                                                                                             2) Business Closure:  (Date) _______________                                                                                                              2) Business Closure:  (Date) _______________ 
  
 Email: __________________________________  Email: __________________________________ 
 Phone: __________________________________                   3) Filing frequency: (Call or Email for change)       Phone: __________________________________                   3) Filing frequency: (Call or Email for change)