7500 W 29th Ave., Wheat Ridge, CO 80033        (303)235-2820 
                                                ONLINE - PAY WITH CARD:  https://salestax.ci.wheatridge.co.us/sts1 
                                             ONLINE - PAY WITH VIRTUAL CHECK:  https://secure.salestaxonline.com 

                           Business name                                                        PERIOD 
                                                                                                COVERED 
                                                                                                DUE 
                                                                                                DATE 
                                                                                                ACCOUNT 
                                                                                                NUMBER 

1                        GROSS SALES AND SERVICES (all revenue)                             5   CALCULATE CITY SALES TAX -  LINE 4 x .035 
                                                                                     .00                                                                          .00 
2A                       ADD: BAD DEBTS COLLECTED                                    .00                                                                          .00 
2B                       TOTAL SALES ACTIVITY - ADD LINES 1 AND 2A                   .00    6   ADD: EXCESS TAX COLLECTED                                         .00 
3                        A      NON-TAXABLE SERVICES                                 .00    7   ADJUSTED TAX – ADD LINES 5 AND 6                                  .00 
                         B      SALES TO OTHER LICENSED DEALERS                      .00    8   DEDUCT VENDOR FEE: LESSER OF 2% OR $100                           .00 
           DEDUCTIONS    C      SALES SHIPPED OUT OF CITY/STATE                      .00    9   TOTAL SALES TAX – LINE 7 MINUS LINE 8                             .00 
                         D      BAD DEBTS CHARGED OFF, TAX PAID                      .00    10  CITY USE TAXABLE AMOUNT                                           .00 
                         E      TRADE-INS FOR TAXABLE RESALE                         .00    11  CITY USE TAX – LINE 10 x .035                                     .00 
                         F      SALES OF GASOLINE/CIGARETTES                         .00    12  TOTAL SALES AND USE TAX DUE – ADD LINES 9 AND 11                  .00 
                         G      SALES TO LICENSED EXEMPT, FEDERAL AND                       13A LATE FILING CHARGES    PENALTY        LARGER OF .10 X LINE 12 OR 
                                COLORADO GOVERNMENTS                                 .00        IF RETURN IS FILED                    $15                         .00 
                         H      RETURNED GOODS                                       .00    13B AFTER DUE DATE ADD     INTEREST       .01 x MONTHS LATE x LINE 12 .00 
                         I      PRESCRIPTION DRUGS, PROSTHETICS                      .00    14  TOTAL TAX, PENALTY, AND INTEREST DUE – ADD LINES 12, 13A AND 13B  .00 
                         J      FOOD STAMPS/SNAP/WIC                                 .00    15  BUSINESS LICENSE RENEWAL FEE DUE BY JANUARY 31 TO AVOID LATE 
                                                                                                FEE                                                               .00 
                         K      OTHER EXEMPT:                                        .00    16A PRIOR PERIOD           DEBIT ON ACCOUNT - ADD 
                         L      OTHER EXEMPT:                                        .00    16B ADJUSTMENTS            CREDIT ON ACCOUNT - SUBTRACT 
3                        TOTAL DEDUCTIONS – ADD LINES 3A THRU 3L                     .00    17  TOTAL AMOUNT DUE                                                  .00 
4                        TOTAL CITY NET TAXABLE LINE 2B MINUS LINE 3                 .00    18  TOTAL AMOUNT PAID  - PLEASE COMPLETE 

                                                       MESSAGES SECTION - TO OR FROM THE CITY 
                      FILE ONLINE FOR CONVENIENCE AND ACCURACY!  ADDRESSES ARE AT THE TOP OF THE PAGE. 

                                                                           INFORMATION SECTION 
                      a)   Please notify about changes using the online tools on the filing websites, a phone call, or email to WRTAX@ci.wheatridge.co.us
                      b)   City Hall walk-in or direct mail:  7500 W. 29 THAVENUE, WHEAT RIDGE, CO 80033-8001
                      c)   Website:  WWW.CI.WHEATRIDGE.CO.US/TAXINFO
                      d)   Tax Division Phone: (303)235-2820

                                                THIS IS A LEGAL DOCUMENT – A SIGNATURE IS REQUIRED 
                           I hereby certify under penalty of perjury that the statements made herein are true and correct to the best of my knowledge. 
Signed:                                                                                                             Date: 
Title:                                                                                                              Phone: 
Company: