Make all remittances payable to: 
COLLECTOR, CLAIBORNE PARISH SALES TAX DEPT.                                 □        Final Return:
  WANDA CLEMENTS, TAX COLLECTOR 
                                                                            Account# 
  P. 0. BOX 600,  HOMER, LOUISIANA 71040
                 PHONE 318-927-3502 

SALES AND USE TAX REPORT 
i SAtES FOR PERIOD OF                                                                                 State Account  #
1. Gross Sales of Tangible Personal Property, Leases, Rentals end Services as Reported to State of Louisiana 
                                                                                                                                                                         I 
                                                  ALLOWABLE DEDUCTIONS 

  2. Sales for Reaala                                                                                                                       lbtThia tu. becomes deUquent 011 day of the month followingththo • 
  3. Cash Olsc:0unts, Sales Relmns & Allawanc:es                                                                                            month for which return is due. After 
  4. Salea Delivered or Shipped outside this Jwfsdlctfon                                                                                    the 10th of the month. penalty an d 
                                                                                                                                               interest l\IDST be iaclndtd. 
  5.  Sal ea of Gasoline and Motor Fuel■                                                                                 ·1 
  6. Sales to U.S. Govt, and Slate of LA & local Gcvt. Agendea 
  7. Salea of Food Paid for With USDA Food Stamps/WIG Vouchars. 
  a.OTHER 
  9.0THER 
  10. OlHER 
11. Total Allowable Oeducllona (Una 2 lhrough 10)                                                                                                           - -
12. Ad/usted Gross Sales for Clalboma Parish: (Une 1 Minus Una 11) 
                                                                            A-3.625%        B-6.000%         C-5.125%       D-4.625%                      E-4.625% 
                                                                            RURAL           HOMER            HAYNESVILLE JUNCTION CITY                    VIUAGEOF 
IMPORTANT: COMPUTATION OF SALES AND USE TAX                                 PARISH          PARISH           PARISH                      PARISH           ATHENS 
                                                                            PJWS            WSHP□Rec.        ws                          PJWS               PJWS 
                                                                            HOSP            HOSP             HOSP                           HOSP            HOSP 
13. Adjusted Gross Salsa In EachJurladlctlcn                                                       -
  14. Purchases Subject to Use Taxln Each Jwfsd!dion 
15. TOTAL ADJUSTED GROSS SALES FOR EACH JURISDICTION 
  (Una 13 Plus Lina 14) 
16. Tax Dua foraach Jwfsd!ctlon-{Multiply Una 13 by% Shown In Column) 
  17. Exc:ass Tax cxillected                                                                                                                                             ·,
18. Total (Una 16 plus Una 17) 
  19. Vandots compensation  2% of Lina 18 if not delinquent. 
20.  NET TAX DUE 
  21. Delinquent Penalty       -5% of Tax for each 30 Days or 
  Fradlon thereof of Del!nQUencv, Not to excaed25% 
  22. Interest per Month fiom Data Dua until Paid:  1.25% 
23. Total Cua Jneludlng Penalty and Interest 
  24. Tax Debit or Credit (Authorited Mamo MUST be Attached) 
25. TOTAL AMOUNT DUE FOR EACH JURISDICTION {After Adjustment) 
                                                                                                                                                                                                       ' 
26. REMITTANCE ATTACHED -TOTAL OF ALL COLUMNS ON LINE 25
                                                                                                                                                                         _J 
I declare under the penalties for fillng false reports that this return  (Including any accompanymg schedule and statements) hes been exammed by me and to the best of my 
knowledge and bellef Is a true, correct and complete return.  lfthe return Is prepared by a person other than a taxpayer his declaration is based on ell the Information 
relating to the matters required to be reported in the return of which he has any knowledge 
WARNING: DO NOT use any other taxpayer's                              DATE:                 SIGN HERE 
return as this   will result in improper credit.