CITY OF ADAK, ALASKA
                                              P.O. BOX 2011 - ADAK, ALASKA 99546-2011
                                              Phone: (907) 592-4500 - Fax: (907) 592-4262
                                                               http://www.adak-ak.us

                                                  SALES TAX RETURN

NOTICE: The Adak Municipal Code §4.06 details the application, exemptions, collections and remittance of sales tax. This report is invalid unless completed in detail.  The 
                 report must be filed even if no receipts for the month.  Information provided on this form is confidential subject to AMC §4.06.90.

                                ALL RETURNS MUST BE FILED - INCLUDING NO SALES

No sales for the month                            Final Tax Return ---------------> Date Closed/Sold:

City Tax ID #:                                                                                                 For Calendar Month/Year:
Business Name:
Address:

1. DETERMINATION OF GROSS RECEIPTS/REVENUE:
A. Sales                                                                                   A.
B. Rentals                                                                                 B.
C. Services                                                                                C.
TOTAL GROSS RECEIPTS/REVENUE (Add lines A thru C):                                                                                         1.                          

2. DETERMINATION OF EXEMPT SALES
A. Government Agencies                                                                     A.
B. Sales Occuring Outside City Limits                                                      B.
C. Other                                                                                   C.
TOTAL EXEMPT SALES (Add lines A thru C):                                                                                                   2.                          

3. SALES SUBJECT TO SALES TAX (Subtract line 2 from line 1):                                                                               3.                          

4. SALES TAX AT 4% (Multiply line 3 by .04):                                                                                               4.                          

5. PENALTY FOR LATE/NON-PAYMENT OF TAX (if applicable):                                                                                    5.

6. INTEREST FOR LATE/NON-PAYMENT OF TAX (if applicable):                                                                                   6.

7. TOTAL DUE (Add lines 4 through 6):                                                                                                      7.                          

MONTHLY SALES TAX RETURNS MUST BE FILED BY THE LAST BUSINESS DAY OF THE MONTH FOLLOWING THE 
CALENDAR MONTH IN WHICH TAXES WERE COLLECTED.

FAILURE TO FILE A REPORT AS REQUIRED WILL RESULT IN A DELINQUENT PENALTY OF 5% PER MONTH OR FRACTION 
THEREOF AND 10% PER MONTH FOR THE FOLLOWING MONTH.  ADDITIONALLY A DELINQUENT INTEREST OF 10.5% PER 
ANNUM OF THE DELINQUENT TAX WILL BE ASSESSED AND DUE.

IF PENALTY AND/OR INTEREST ARE INCORRECTLY CALCULATED THE DIFFERENCE WILL BE INVOICED WHICH WILL BE 
IMMEDIATELY DUE AND PAYABLE.

I CERTIFY UNDER PENALTY OF PERJURY THAT THIS RETURN (INCLUDING ANY ACCOMPANYING STATEMENTS HAS BEEN 
EXAMINED BY ME AND TO THE BEST OF MY KNOWLEDGE AND BELIEF IS A TRUE, CORRECT AND COMPLETE RETURN. 

SIGNATURE & TITLE                                                                                              Date
                                                                                                                                                               (Rev. 07/2014) 

                    CITY OF ADAK, ALASKA
                    P.O. BOX 2011 - ADAK, ALASKA 99546-2011
                    Phone: (907) 592-4500 - Fax: (907) 592-4262
                                     http://www.adak-ak.us

                    SALES TAX RETURN

                             SCHEDULE A - EXEMPTIONS

City Tax ID #:                                            For Calendar Month/Year:
Business Name:

A. GOVERNMENT/EXEMPT AGENCIES
Date           Government Agency Name                     Agency Type         Amount

                                      Total Government Agency Sales:

B. SALES OCCURING OUTSIDE CITY LIMITS
Date           Name                   Description of Sale                     Amount

                                     Total Sales Occuring Outside City Limits:

C. ALL OTHER SALES CLAIMED EXEMPT (MUST HAVE CITY ISSUED CERTIFICATE - NO EXCEPTIONS)
Date                Name                                  Certificate No.     Amount

                                      Total Other Sales Claimed Exempt:                               

                                                                                     (Rev. 07/2014)