TAXPAYER’S NAME AND ADDRESS
 PERIOD                                                                    ACCOUNT
 COVERED                                                                   NUMBER                                                                                                         CITY OF DELTA
 DUE                                                                                                                                                                               SALES & USE TAX RETURN
 DATE
                                                                                                                                                                                          P.O. Box 19 • Delta, CO 81416-0019
                                                                                                                                                                                                        (970) 874-7566
                                                                                                                                                                                                        COMPUTATION OF TAX
                                                                                                                              5.  TOTAL CITY SALES TAX (3% OF LINE 4)
                                                                                                                              6.  EXCESS TAX COLLECTED
                                                                                                                              7.  ADJUSTED CITY SALES TAX (ADD LINES 5 & 6)
                                                                                                                              8.  VENDORS FEE (0% OF LINE 7)
                                       TOTAL RECEIPTS FROM CITY ACTIVITY MUST BE REPORTED AND ACCOU                           9.  TOTAL CITY SALES TAX (LINE 7 MINUS LINE 8)
    & SERVICE
1.  GROSS SALES           (ASES,NTED FORANDINALLEVERYSERVICESRETURN,BOTHINCLUDINGTAXABLEALLANDSALES,NON-TAXABLE.RENTALS AND)LE10.  CITY USE TAX                    SCHEDULE(FROM B)AMOUNT SUBJECT TO TAX _______________________________ X 3% =
2A. BAD DEBTS COLLECTED                                                                                                       11.  TOTAL CITY SALES & USE TAX (ADD LINES 9 & 10)
                                                                                                                                        LATE FILING                                ADD:   PENALTY                              TOTAL
                                                                                                                                        IF RETURN IS FILED                                                                     PENALTY &
2B. TOTAL CITY GROSS TAXABLE(SALESINCLUDEDLINE 1 ABOVE&ONSERVICE)          (ADD LINES 1 & 2A)                                 12.  (AFTER DUE DATE THEN )                                 MONTHINTEREST PER 10%                INTEREST
3.  A. SERVICE SALESNON-TAXABLE                                                                                                                                                                             .9167%
    B. FOR PURPOSES OF TAXABLE RESALESALES TO OTHER LICENSED DEALERS                                                          13.  TOTAL CITY SALES & USE TAX, INCLUDING PENALTY & INTEREST (ADD LINES 11 & 12)
D      SALES SHIPPED OUT OF                                                                                                             ADJUST PRIOR PERIOD(S)                            A – ADD:
E   C. CITY AND/OR STATE                  (INCLUDED ONLINE 1 ABOVE )                                                          14.       (ATTACH COPY OF NOTICE                            B – DEDUCT:
D   D. CHARGEDBAD DEBTSOFF            (ON WHICHHAS BEENCITY SALESPAID TAX)                                                              RECEIVED FROM CITY)
U   E. TRADE-INS FOR TAXABLE RESALE                                                                                           15.  TOTAL DUE AND PAYABLE (MAKE CHECK PAYABLE TO THE CITY OF DELTA)
C
T   F. SALES OF GASOLINE & CIGARETTES
I
O   G. ANDSALESCHARITABLETO GOVERNMENTAL,ORGANIZATIONSRELIGIOUS
N   H. RETURNED GOODS
S                                                                                                                                                                                         DO NOT ROUND FIGURES
    I. PRESCRIPTION DRUGS/PROSTHETICS                                                                                                                                              SCHEDULE - A - SPECIAL MESSAGE FROM TAXPAYER
    J. OTHER DEDUCTIONS (LIST)
    K.
    L.
3.  TOTAL DEDUCTIONS (ADD LINES 3A THRU 3L)
4.  TOTAL CITY NET TAXABLE SALES & SERVICE (LINE 2B MINUS LINE 3)                                                                                                                  PLEASE COMPLETE THIS FORM ON REVERSE SIDE

                                                                   BE SURE TO REVERSE CARBON BEFORE FILLING OUT THESE SCHEDULES
                                  SCHEDULE - B - CITY USE TAX                                                                     SCHEDULE - C - CONSOLIDATED ACCOUNTS REPORT
The Delta Municipal Code imposes a tax upon the privilege of using, storing, distributing or otherwise consuming tangible This schedule is required in all cases in which the taxpayer makes a consolidated return, which includes sales made at more 
personal property or taxable services purchased, rented or leased.                                                        than one location. It must be completely filled out and convey all information required in accordance with the column head-
                                                                                                                          ings. If additional space is needed, attach schedule in same format.
DATE OF            NAME OF VENDOR            TYPE OF COMMODITY                PURCHASE                                    ACCOUNT BUSINESS ADDRESSES          PERIODS TOTAL GROSS                   PERIODS NET TAXABLE
PURCHASE           ADDRESS                          PURCHASED                        PRICE                                NUMBER  OF CONSOLIDATED ACCOUNTS    SALES (AGGREGATE TO                   SALES (AGGREGATE TO
                                                                                                                                                              LINE 1 FRONT OF RETURN)               LINE 4 FRONT OF RETURN)
         LIST OF PURCHASES (IF ADDITIONAL SPACE IS NEEDED, ATTACH SCHEDULE IN SAME FORMAT)                                                                  $                                 $
                                                                           $

         TOTAL PURCHASE PRICE OF PROPERTY SUBJECT TO CITY USE TAX
                   (ENTER ON LINE 10 ON FRONT OF RETURN)
                                                                           $                                              TOTALS (ENTER ON FRONT OF RETURN) $                                 $

                                                                                           SHOW BELOW CHANGE OF OWNERSHIP AND/OR ADDRESS, ETC.              I hereby certify under penalty of perjury, that the statements made 
MO.NEW BUSINESSDAY DATEYR. 1. If business ownership has changed, give date of change and   NAME  ___________________________________________________        herein are to the best of my knowledge, true and correct.
                               new owners name, address and phone.                                                                                          SIGNED BY  ___________________________________________________
                           2. If business has been permanently discontinued, give date     ADDRESS  _______________________________________________
DISCONTINUED DATE              discontinued.                                               _________________________________________________________        PRINT NAME  __________________________________________________
MO.      DAY       YR.     3. If business location has changed, give new business address                                                                   TITLE  ________________________________________________________
                               and mailing address.                                        PHONE   __________________________________________________
                                                                                                                                                            PHONE ___________________________________    __________________
                                                                                                              BUSINESS ADDRESS             MAILING ADDRESS                                                                                                DATE