PO BOX 912758, DENVER, CO 80291-2758        (303)235-2820 
                                                ONLINE - PAY WITH CARD:  https://salestax.ci.wheatridge.co.us/sts1 
                                             ONLINE - PAY WITH VIRTUAL CHECK:  https://secure.salestaxonline.com 
                                                                                                       
                                                                                                   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: