Wyoming Dept of Revenue
                                                                      Wyoming Sales & Use Tax                                               122 W 25th St, 2W
                                                                                                                            Cheyenne, WY 82002-0110
                            Form 41-1                                 Return for Licensed Vendors                                                               
                            For Dept Use Only

Please use black ink to complete form
SST ID:                                                                                       Ownership RID: 

                                                                                              License Number: 
              Name & Address
                                                                                              Report Period:                     through 
                                                                                              Return Due Date: 
                                                                                                          Check here if this is an amended return
                                                                                                       Check here if no sales or taxes to report

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

Line A.                     Gross Sales & Services (Total Sales)

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 M)

Line E.                     Lodging Tax Due (Complete Part IV supplement if any lodging taxes due, otherwise enter zero)

Line F.                     Total Taxes Due (Line D plus Line E)

Line G.                     Vendor Compensation Credit

Line H.                     Penalties, Interest or Dept. of Revenue Billing (See instructions)

Line I.                     Credit Memo from Dept. of Revenue (See instructions)

Line J.                     Total Amount Due (Subtract Line G from F, then Add Line H and Subtract Line I)

Part II - Jurisdictional Tax Information
(Col 1)                     (Col 2)          (Col 3)                  (Col 4)                 (Col 5)     (Col 6)                        (Col 7)
Jurisdiction                Jurisdiction     Tax Rate           Sales Tax Due    Use Tax Due              Excess          Net Tax Due
Name Code                   Digit Code       % in Effect                                                   Tax Due        (Add Columns 4, 5, & 6)
                                                                                                                                          
                                                      %

                                                      %

                                                                      Line K. Total Net Tax (Add totals in Column 7) 

Total Number                                 Line L.        Sum of Line 1 results from all Part III Supplemental Pages 
Supplemental 
Pages Included                               Line M.        Total Jurisdictional Tax Due (Add Lines K & L. Enter results 
                                                                                              here & on Part I, Line D

Please attach an additional page with any changes pertaining to: address, ownership or contact information changes.
                                                                                                      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:
Date business permanently closed:                                                             Name (Printed):