SALES TAX DEPARTMENT
                                                                                                            P.O. BOX 440 - FORT COLLINS, CO  80522-0439
                                                                                                            970-221-6780            FAX:  970-221-6782 
                                                                                                            EMAIL:  salestax@fcgov.com 
                                                                                                            www.fcgov.com/salestax
                                                                                                                                    COMPUTATION OF TAX
PERIOD COVERED               DUE DATE                   ACCOUNT NUMBER                                 5A AMOUNT OF CITY SALES TAX :  3.85% OF LINE 4
                                                                                                       5B GROCERY FOOD SUBJECT 
                                                                                                          TO TAX (LINE 3L)     $____________________ X 2.25%
1 GROSS SALES (TOTAL RECEIPTS FROM CITY ACTIVITY MUST BE                                                                                                    
  AND SERVICE REPORTED & ACCOUNTED FOR IN EVERY                                                        6  EXCESS TAX COLLECTED
              RETURN INCL. ALL SALES, RENTALS, LEASES, & 
              ALL SERVICES, BOTH TAXABLE & NON-TAXABLE)
                                                                                                       7  ADJUSTED CITY TAX (ADD Lines 5A, 5B, and 6)
2A ADD: BAD DEBTS COLLECTED
                                                                                                       8  CURRENTLY NOT USED
2B TOTAL LINES 1 & 2A
   A NON-TAXABLE      (INCLUDED IN                                                                     9  TOTAL SALES TAX (LINE 7)
3    SERVICE          ITEM 1 ABOVE)
   B SALES TO OTHER LICENSED                                                                           10 NET TAXABLE SUBJECT TO USE TAX (FROM SCHEDULE B)
     RETAILERS FOR PURPOSES OF 
D    TAXABLE RESALE                                                                                    11 USE TAX:  3.85% OF LINE 10
E  C SALES SHIPPED OUT   (INCLUDED IN 
     OF CITY &/OR STATE  ITEM 1 ABOVE)                                                                 12 LATE FILING:      PENALTY: 10%                      ENTER 
D  D BAD DEBTS CHARGED OFF                                                                               IF RETURN IS FILED                                   TOTAL
U     (ON WHICH CITY SALES TAX HAS                                                                        AFTER DUE DATE    INTEREST PER 
C    BEEN PAID)                                                                                           THEN ADD:         MONTH:  1%                       
   E TRADE-INS FOR TAXABLE RESALE
T                                                                                                                           ASSESSMENT FEE           $25.00
I  F SALES OF GASOLINE  AND 
     CIGARETTES                                                                                        13 TOTAL TAX, PENALTY AND INTEREST DUE (ADD LINES 9, 11, 12)
O  G SALES TO GOVERNMENTAL/
N    RELIGIOUS & CHARITABLE ORGS                                                                       14 ADJUSTMENTS FOR PRIOR PERIODS - ATTACH COPY OF NOTICE
S  H RETURNED GOODS
   I PRESCRIPTION DRUGS/                                                                               15 TOTAL DUE AND PAYABLE:
     PROSTHETIC DEVICES                                                                                   MAKE CHECK PAYABLE TO: CITY OF FORT COLLINS
   J FOOD STAMPS
   K LODGING OVER 30 DAYS                                                                              SCHEDULE A
   L GROCERY FOOD SALES
   MOTHER
3  TOTAL DEDUCTIONS      (TOTAL OF LINES 3A THRU 3M)
4  TOTAL CITY NET TAXABLE SALES & SERVICES
     (LINE 2B MINUS TOTAL LINE 3)

                        SCHEDULE B - CITY USE TAX
   The use tax ordinance imposes a tax upon the privilege of using, storing, distributing or otherwise 
   consuming in the city tangible personal property or taxable services purchased, rented or leased.
DATE OF       NAME OF VENDOR       TYPE OF COMMODITY     PURCHASE PRICE                                       ON-LINE FILING IS NOW AVAILABLE AT
PURCHASE
                                                                                                                            https://salestax.fcgov.com

                                                                                                                    Additional information can be found at 
                                                                                                                            http://www.fcgov.com/salestax

(B) TOTAL PURCHASE PRICE OF PROPERTY SUBJECT TO CITY USE 
  TAX - ENTER TOTAL LINE (B) ON LINE 10 ON TOP OF RETURN
   SHOW BELOW ANY CHANGE OF BUSINESS NAME, OWNERSHIP, OR ADDRESS                                       I HEREBY CERTIFY UNDER PENALTY OF PERJURY, THAT THE STATEMENTS MADE HEREIN 
                                                                                                                 ARE TO THE BEST OF MY KNOWLEDGE, TRUE AND CORRECT.
                                                                                                       COMPLETED BY 
                                                                                                       (PRINT NAME):
                                                                                                       TITLE:
       BUSINESS ADDRESS                 MAILING ADDRESS                                              SIGNATURE:
                                                                                                       COMPANY
DATE BUSINESS CLOSED:                                                                                  PHONE:
                                                                                                       E-MAIL:
                                                                                                       DATE: