Wyoming Sales & Use Tax                            Wyoming Department of Revenue
                                                                                        122 West 25th Street, Suite E301
        Form 41-2                    Supplement for Licensed Vendors                    Cheyenne, Wy 82002

Please use black ink to complete form
Name                                               Ownership RID: 
                                                   License Number: 
                                                   Report Period:               through 

Part III - Jurisdictional Tax Information - Do not use dollar signs, commas or periods
(Col 1)     (Col 2)      (Col 3)     (Col 4)       (Col 5)        (Col 6)               (Col 7)
Jurisdiction
                                                                                        Net Tax Due
Name Code   Jurisdiction Tax Rate    Sales Tax Due Use Tax Due    Excess                (Add Columns 4, 5, & 6)
(Use CAPS)  Digit Code   % in Effect                           Tax Due
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Line 1. Total Net Tax (Add totals in Column 7) Enter results here and on Part II, Line L
                                                               of Form 41-1

                                                                                        Revised 1.23.2020