FILING PERIOD (Required)
                   SALES                         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:                                                   -
                                                                                                   ( Line 5 plus line 6)

                                                                                           8. Vendor Fee:         (line 7 times 3%)                                       -
  *** Message ***                                                                              Max = $200, Enter -0- on Late Return
                                                                                          9.  Net Broomfield City and County
                                                                                                                                                                          -
Save time, postage and paper when you file online.  Please                                     Sales Tax: (line 7 minus line 8)
  visit www.broomfield.org/salestax  click “Citizen Access 
                   Online” on the left.                                                   10. Lodging 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.   Late Filing Penalty:
                                                                                      -   
  (Line 1 plus 1a)                                                                             ( See Instructions)
3. Exemptions:                                                                            13.   Interest:
                                                                                      -   
  (Please insert total of line 3 from page 2 )                                                 ( See Instructions)
4.  Net Taxable Sales & Services:                                                         14.   Adjustments:  See Instructions
                                                                                      -   
  (Line 2 minus line 3 )                                                                       ( Attach Authorization Letter)
5. Broomfield City and County                                                             15.   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:                                                                                                   $$$                                -                                                                                                                             -                                            -

ADDRESSADDRESS    CHANGES:CHANGES:                                                                                                                                                            BUSINESSBUSINESS  STATUSSTATUS CHANGES:CHANGES:              

MailingMailing  address:address: __________________________________________________                                                                 1)1) OwnershipOwnership (Date,(Date,                                       NewNew      OwnerOwner      andand       Phone)Phone)  
City,City, StateState                              ________________________________________________                                                  ________________________________________________________________________                              
Zip:Zip:                                              __________________________________________________                                                  ________________________________________________________________________
LocationLocation address:address:                     __________________________________________________                                          
                                                                                                                                                                                              2)2) BusinessBusiness  Closure:Closure:  (Date)(Date)    ______________________________  

Email:Email: ____________________________________________________________________  
Phone:Phone: ____________________________________________________________________                                                                   3)3) FilingFiling frequency:frequency:                                   (Call(Call    oror      EmailEmail forfor  change)change)