Received Date: 

                    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                                                                              Business ID No. 

Mailing Address                                                                            Phone  

Type of Report:     □ Gaming        □ Last Report for Season              □ Final Report          □ Amended 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                                                                             (a) 
b. Exempt Sales (e.g. Food Stamps, WIC, Resale)                                                              (b) 
c. Sales in Excess of $3,500 (Enter amount of excess only and attach log)                                    (c) 

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. Total Due (Total lines 4 and 7)                                                                           (8) 

9. Credits on account (contact finance to verify amount)                                                     (9) 

10. Total Amount Remitted (subtract line 9 from line 8)                                                      (10) 

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 and adheres 
to Dillingham Municipal Code 4.20 and/or 4.23.  
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 
FIN101 Rev. 01.2023                             www.dillinghamak.us