CITY OF DILLINGHAM  
                                             6% SALES TAX                 REPORTING FORM 
                                       
                     Reports must be filed by the last day of the calendar month of collection following the month 
of collection, or not later than the first day City Hall is open for regular business.  A postmark will be accepted as 
proof of timely filing.  
 
Please type or print legibly 
 
Business Name                                                       Busin                             ess ID No.           

 Mailing Address                                                    FIN, EIN or SSN                                       

 Type of Report:            Gaming                   Last Report for Season                           Final Report 

                 Monthly                      Quarterly Period Ending:  Month                            Year              
  
 1.  Gross Sales (Do not include sales tax collected.)                                                _______________________(1) 
        Receipts from all sources including, but not limited to, retail sales of merchandise,  
        services rendered, including material furnished, rental of property and equipment.  
 2.  Less All Non-Taxable Sales (Include Sales Tax Exemption Log.)                                    _______________________(2) 
     a. Sales to Exempt Organizations                               `                                               
     b. Exempt Sales (e.g. Food Stamps, WIC, Resale)                                                                
     c. Sales in Excess of $3,500 (Enter amount of excess only and attach log.)                                     
 3.  Net Taxable Sales  (Subtract Line 2 from Line 1)                                                                     (3) 
 4.  Amount of Tax Due        (6% of Line 3)                                                                              (4) 
 5.  Penalty   (Late Filing - 10% of tax due Line 4, per DMC 4.20.220.B)                                                  (5) 
 6.  Interest  (Late Filing - 6% per annum from date of delinquency per DMC 4.20.220)                                     (6) 
 7.  Total Penalty and Interest  (Total of lines 5 and 6)                                                                 (7) 
 8.  Adjustments from Previous Month                                                                    (8)                       
 9.  Total Lines 4, 7 and 8                                                                             (9) 
 10. Less Collection Discount (May withhold 1% of Line 4 not to exceed $100 if paid on time,                              (10) 
     and if past due sales tax or penalties are not due, and there are no existing sales tax related  
     delinquencies per DMC 4.20.150.) 
 11. Total Due  (Subtract line 10 from line 9)                                                                            (11) 
 12. Total Amount Remitted                                                                                                (12) 
 Comments: 
 I declare, subject to the penalties prescribed in the City of Dillingham ordinances, that this report (including any accompany log) has been 
 examined by me, and to the best of my knowledge and belief is a true, correct and complete report.  
 Date                                 Signature                                                                            
  
 This section is to be completed by City of Dillingham Finance Department.                                       Visa     Cash 

 Employee Initials                   Postmark Date           Enter Date                                          Check #           
                                  141 Main Street PO Box 889Dillingham, Alaska  99576 
                                         Finance Department (907)842-5211    Fax (907)842-5691 
                                                      www.dillinghamak.us