This report is DUE on the 1st day of the                      REMIT TO  :
month   following period covered by             IBERVILLE PARISH SALES TAX                          Check #: 
     the report, and becomes                             DEPARTMENT                                 Postmark Date: 
DELINQUENT ON 21ST DAY                          P.O. Box 355· Plaquemine, LA 70765-0355             Date Received: 
FORM EFFECTIVE APRIL 2015 TAX PERIOD            SALES &       USE TAX REPORT                        Receipt #: 
                                                Ph.(225) 687-5200 • Fax (225) 687-5226              ReceiptDate: 
Account # _____                                          www.ibervillepansh.com                                       (FOR OFFICE USE    ONLy) 
(Do Not use any other taxpayer's return as this may result in improper credit.)        Tax Report for the         Period ________ 

                                                                                       Col. A (5.000%) 
                                                                                       Parishwide 
                                                                                       excluding 
                                                                                   City of St. Gabriel 

                                                                                               HAVE YOU USED THE PROPER       COLUMN? 
                                                                                                -

                                                                         Phone Number  for Contact Person                     Reviewed   By 
Parish Account Number                           State Tax ID Number 

                                                                                       1:.11 .  •  IIf·U::lr·H.·..tI: '1~ltI; I:tl:l:l" 
                                                                        o FINA~ IDate business closed                 Date business sold 
                                                                        RETURN 
                                                                        Name    of New Owner 

                                                                        Mailing address change 

                                                                        Location address change 
                                                                                                                                         Rev. 02115