Wyoming Dept of Revenue
                                                            Wyoming Sales & Use Tax                                         122 W 25th St, 2W
               Form 42-1                                    Return for Annual Vendors                              Cheyenne, WY 82002-0110
               ĸ )RU 'HSW 8VH 2QO\ ĺ

Please use black ink to complete form
SST ID:                                                                          Ownership RID: 

Name & Address                                                                   License Number: 
                                                                                 Report Period:                     through 
                                                                                 Return Due Date: 
                                                                                 Check here if this is an amended return
                                                                                  Check here if no sales or taxes to report

Part I - Summary - Do not use dollar signs, commas or periods                                                               (Dollars)   (Cents)
Line A.        Gross Sales & Services (Total Sales)

Line B.        Total Deductions (Sales & services which are exempt or not taxed)

Line C.        Net Taxable Sales & Services (Line A minus Line B)

Line D.        Jurisdictional Taxes Due (Part II, Line K)

Line E.        Vendor Compensation Credit

Line F.        Penalties, Interest or Dept. of Revenue Billing (See instructions)

Line G.        Credit Memo from Dept of Revenue (See instructions)

Line H.        Total Amount Due (Subtract Line E from Line D, Add Line F, then subtract Line G)

Part II - 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          Col 8
Jurisdiction   Jurisdiction Tax Rate      Select quarter(s)      Sales Tax Due   Use Tax Due      Excess Tax                Net Tax Due 
                                          where taxes were 
Name Code      Digit Code           % in  collected at rate in                                               Due            (Add Columns 
(Use CAPS)                  Effect           Column 3
                                                                                                                            5, 6, & 7)
                                          Q1 Q2          Q3 Q4
                                         %

                                         %

                                         %

                                         %
                                                         Line I. Total Net Tax (add totals in Column 8) 
Total Number 
Supplemental                Line J.       Sum of Line 1 results from all Part III Supplemental Pages 
Pages 
Included with 
This Return                                                      Line K.         Total Jurisdictional Tax Due
                                          (Add Lines I & J. Enter results here & in Part I, Line D)

Please attach an additional page with any changes pertaining to: address, ownership or contact information changes.
                                                                                 Date:
Signature:
                                                                                 Title:
I declare, under penalty of perjury, that I have examined this return and to the 
best of my knowledge and belief it is correct and complete.                      Phone Number:
Date business permanently closed:                                                Name (Printed):