WASHINGTON PARISH SHERIFF'S OFFICE SALES AND USE TAX REPORT 
                                                                            WASHINGTON PARISH 
                                                                            SHERIFF'S  OFFICE 
                                                                          SALES AND USE TAX DEPARTMENT 
                                                                            P.O.  BOX 508 
                                                                          FRANKLINTON LOUISIANA 70438 
                                                               (985) 839-3434/FAX  (985) 839-6581 
  STATE OF LOUISIANA TAX I.D. NO.                                                             MONTH OF 
  1 GROSS SALES OF TANGIBLE PERSONAL PROPERTY. LEASES, RENTALS                                                             Make all Remittances 
      AND SERVICES AS REPORTED TO THE STATE OF LA                                                                             Payable to 
                            ALLOWABLE DEDUCTIONS                                                                           WASHINGTON PARISH 
  2 SALES FOR RESALE                                                                                                         SHERIFF'S OFFICE 
  3 CASH DISCOUNTS, SALES RETURNS AND ALLOWANCES                                                         SALES TAX DEPARTMENT 
  4 SALES DELIVERED OR SHIPPED OUTSIDE THIS JURISDICTION 
  5 SALES OF GASOLINE AND MOTOR FUELS                                                                    PARISH OF WASHINGTON 
  6 SALES TO AGENCIES OF THE U.S. GOVT., THE STATE OF LOUISIANA AND                                                           LOUISIANA 
1   ITS POLITICAL SUBDIVISIONS 
  7 SALES OF FOOD PAID FOR WITH USDA FOOD STAMPS OR WIC VOUCHER                                          SALES AND USE TAX REPORT 
             OTHER DEDUCTIONS AUTHORIZED BY LAW (Explain Briefly) 

                                                                                                         month following the period covered by the 
                                                                                                         return, and becomes DELINQUENT on 
                                                                                                                              the 21st  day. 
  I1TOTAL ALLOWABLE DEDUCTIONS (Lines 2             thru10)                                 I 

  WASHINGTON PARISH, LOUISIANA 
                                                                          I             I     I        I                   I  -                                   I 
  13  ADJUSTED GROSS SALES IN EACH JURISDICTION 
  (Total of Columns must equal line 12)                                   I             1 '   I        I                   I                                      I I 
  14 PURCHASE SUBJECT TO USE TAX IN EACH JURISDICTION                     I             I     I        I                   1                                      I I 
  1 5  TOTAL (Line 13 plus line 14) 
  16  TAX (% dam 15) multiply line 15 by percent shown at top of wlumn(s) 
  17  EXCESS TAX COLLLECTED 
  18 TOTAL (Line 16 plus line 17) 
  19  VENDOR'S COMPENSATION%(1  of line 18 deductible 
      onlv when Davment is not delinauent 
  20  NET TAX DUE (Line 18 minus line 19)                                 I             1     I        1                   I                                      I 1 
  21  DELINQUENT PENALTY (5% of tax for each 30 days or 
     fraction thereof of delinquency, not to exceed 25% in the aggregate 
  22  INTEREST (1.25% per month or fractional part thereof, 
  from date due until paid) 
  23  TOTAL TAX, PENALTY AND INTEREST DUE 
  24  TAX DEBIT OR CREDIT (Authorized memo must be attached) 
  25  TOTAL AMOUNT DUE (Line 23 plus or             minus line 24) 
  26  REMllTANCE AlTACHED                                                                     TOTAL OF LINE 25 (COLUMNS A. B. C.D.E.F) 

  ACCT #:                                                                 SIGNATURE OF 
  ACCT NAME:                                                              INDIVIDUAL OR AGENT            DATE 

  PLEASE INDICATE ANY CHANGES BELOW:                                      WARNING: DO NOT use any other taxpayef s returns as this will result in improper credit 
  NAME OF NEW OWNER                                                         DO NOT ignore delinquent notices-  negligence penalties may be imposed 
  DATE OUTOF BUSINESS 
  DATE BUSINESS SOLD 

  COMMENTS: