Wyoming Dept of Revenue
                                                                      Wyoming Sales Tax                                             122 W 25th St, 2W
                            Form 43-1                                 Return for Occasional Vendors                                 Cheyenne, WY 82002-0110 
                            ĸ )RU 'HSW 8VH 2QO\ ĺ

Please use black ink to complete form
                                                                                              Ownership RID: 

                                                                                              License Number: 
              Name & Address
                                                                                              Report Period:                through 
                                                                                              Return Due Date: 
                                                                                               &KHFN KHUH LI WKLV LV DQ DPHQGHG UHWXUQ ĺ 
                                                                                                &KHFN KHUH LI QR VDOHV RU WD[HV WR UHSRUW ĺ 

Part I - Summary - Do not use dollar signs, commas or periods                                                                       (Dollars)     (Cents)

Line A.                     Gross Sales & Services
Line B.                     Total Deductions (Sales & services which are exempt or not taxed)
Line C.                     Net Taxable Sales & Services (Line A minus Line B)
Line D.                     Jurisdictional Taxes Due (Part II, Line L)
Line E.                     NOT USED
Line F. NOT USED
Line G.                     Penalties, Interest or Dept. of Revenue Billing (See instructions)
Line H.                     Credit Memo from Dept. of Revenue (See instructions)
Line I.                     Total Amount Due (Add Lines D & G, then subtract Line H)
Part II - Jurisdictional Tax Information
(Column 1) (Column 2) (Column 3)                          (Column 4)                (Column 5) (Column 6)                           (Column 7)
Jurisdiction                Jurisdiction Tax Rate         Sales Tax Due                        Excess                               Net Tax Due 
Name Code                   Digit Code   % in Effect                                NOT USED   Tax Due                (Add Columns 4 & 6)
(Use CAPS)
                                                  %
                                                  %
                                                  %
                                                  %
                                                                       Line J. Total Net Tax (Add totals in Column 7) 
Total Number                                      Line K. Sum of Line 1 results from all Part III Supplemental Pages 
Supplemental 
Pages Included                           Line L. Total Jurisdictional Tax Due (Add Lines J & K. Enter results here & 
                                                                                               on Part I, Line D 
Please check appropriate box for:                                      Changed Information:
                            Location Address Change?                  ĺ
                            Mailing Address Change?                   ĺ
                            Ownership Change?                         ĺ
                            Authorized Contact Change?                ĺ
                                                                                               Date:
Signature:
                                                                                               Title:
I declare, under penalty of perjury, that I have examined this return and to the 
best of my knowledge and belief it is correct and complete.                                   Phone Number:
                                                                                              Name (Printed):