Wyoming Dept of Revenue
                                                Wyoming Sales & Use Tax                                    122 W 25th St, 2W
                                                                                           Cheyenne, WY 82002-0110
                Form 41-2                       Supplement for Licensed Vendors                                                 

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