CITY OF GRAND JUNCTION 
                                                Finance 
                                 250 N. 5th Street, Grand Junction, CO 81501 
                                         (970) 244-1521   Fax (970) 256-4078 
                                              
                                           CITY USE TAX RETURN 

NAME OF TAXPAYER:                                                                                                                           

ADDRESS:                                                                                   TELEPHONE #:                          _________ 

A.    SCHEDULE  OF  TANGIBLE  PERSONAL  PROPERTY  USED,  STORED,  CONSUMED  WITHIN  THE  CITY  OF  GRAND 
      JUNCTION FOR THE MONTH(S) OF                                                          20_______ {COVERED IN THIS RETURN}: 

    PURCHASE                                                                                     VENDOR                    PURCHASE 
      DATE          DESCRIPTION                 VENDOR                                      ADDRESS                              PRICE 

1.                                                                                                                  $                       

2.                                                                                                                  $                       

3.                                                                                                                  $                       

4.                                                                                                                  $                       

5.                                                                                                                  $                       
             (If there are additional purchases, please attach list) 
             TOTAL PURCHASE PRICE                                                                         LINE (A)     $                    
              
B.    USE TAX DUE: 
      Total Purchase Price {line (A)                                                 }                           $                          
      City of Grand Junction Use Tax Rate                                                                                        x 2.75% 
      TAX DUE                                                                                                    $                          
      Interest of 1.5% of Tax Due (For each month or portion of month overdue)                                   $                          
      Penalty of 10% of Tax Due (Minimum $15.00)                                                                 $                          
      TOTAL AMOUNT  UED     {Make check payable to City of Grand Junction                                        $                          
                                           Mail to: City of Grand Junction 
                                           Finance 
                                           250 N. 5 thSt 
                                           Grand Junction, Colorado 81501} 

I hereby certify that I have examined this return and that it is to the best of my knowledge and belief a true and complete 
return made in good faith for the period hereinabove stated. 

Name:                                                                                      Title:                                           
                          (please print) 

Signed:                                                                                  Date:                                    

Form #GJ400 (02/18)