CITY OF GRAND JUNCTION                FINANCE - SALES TAX
PERIOD                                            DUE                          ACCOUNT              250 NORTH 5TH ST., GRAND JUNCTION, COLORADO  81501-2668        970-244-1521
COVERED                                           DATE                         NUMBER
                        TOTAL RECEIPTS FROM CITY ACTIVITY MUST BE REPORTED AND
1.    GROSS SALES       ACCOUNTED FOR IN EVERY RETURN INCL. ALL SALES RENTALS
      AND SERVICE       AND LEASES AND ALL SERVICES BOTH TAXABLE AND NON-
                   ( TAXABLE.                                                )                                              COMPUTATION OF TAX
2A.   ADD:  BAD DEBTS COLLECTED                                                        5. AMOUNT OF CITY SALES TAX:  3.25% OF LINE 4
2B.   TOTAL LINES 1 & 2A                                                               6. ADD:  EXCESS TAX COLLECTED  
3. A. NON-TAXABLE  (INCLUDED IN ITEM 1 ABOVE)                                          7. ADJUSTED CITY TAX:  (ADD LINES 5 AND 6)
      SERVICE SALES
  B.  SALES TO OTHER LICENSED DEALERS                                                  8. DEDUCT:  3.333% OF LINE 7 (VENDOR'S FEE IF PAID BY DUE DATE)                    
      FOR PURPOSES OF TAXABLE RESALE                                                       ***MAXIMUM DEDUCTION ALLOWED IS $500***
D C.  SALES SHIPPED OUT OF    INCLUDED IN                                              9. TOTAL SALES TAX:  (LINE 7 MINUS 8)
      CITY AND OR STATE    (  ITEM 1 ABOVE)
                         ON WHICH CITY SALES TAX
      CHARGED OFF
E D.  BAD-DEBTS         (     HAS BEEN PAID     )                                      10. AMOUNT SUBJECT TO ORIGINAL LODGING TAX:                                                                         XX  3.00% =    3.00% =
D E.  TRADE-INS FOR TAXABLE RESALE                                                     11. DEDUCT:  3.333% OF LINE 10 (LODGING VENDOR'S FEE IF PAID BY DUE DATE - NO 
                                                                                           MAX)                
U F.  SALES OF GASOLINE AND CIGARETTES                                                 12. AMOUNT SUBJECT TO 2019 LODGING TAX INCREASE:                                 
                                                                                           (NO VENDOR'S FEE APPLIED TO 3% INCREASE)                                                                          X 3.00% =  
C G.  SALES TO GOVERNMENTAL, RELIGIOUS                                                 13. TOTAL LODGING TAX:  (LINE 10 MINUS 11 PLUS 12)
      AND CHARITABLE ORGANIZATIONS
T H.  RETURNED GOODS                                                                   14. TOTAL SALES & LODGING TAX:  (LINE 9 PLUS 13)
                           PROSTHETIC                                                      (FROM SCHEDULE B)
I I.  PRESCRIPTION DRUGS / DEVICES                                                     15. CITY USE TAX - AMOUNT SUBJECT TO TAX                                                                          X     3.25% =
O J.  FOOD STAMPS                                                                      16. TOTAL TAX DUE:  (ADD LINES 14 AND 15)
                                                                                                                                  10% OF LINE 16                                                               ENTER
N K.  LODGING OVER 30 DAYS                                                                 LATE FILING                 PENALTY:   OR $15 MIN.                                                                  TOTAL
                                                                                       17.
S L.  FOOD FOR HOME CONSUMPTION                                                            IF RETURN IS FILED          INTEREST
                                                                                           AFTER DUE DATE THEN ADD:    PER MONTH: 1.5% OF LINE 16
  M.  OTHER DEDUCTIONS (LIST)                                                          18. TOTAL TAX, PENALTY AND INTEREST DUE: (ADD LINES 16 AND 17)
  N.                                                                                       ADJUSTMENT PRIOR PERIODS    A - ADD:
                                                                                       19. ATTACH COPY OF OVER OR
  O.                                                                                       UNDERPAYMENT NOTICE         B - DEDUCT:
                                                  TOTAL OF LINES 3
      3.  TOTAL DEDUCTIONS                      (  A THRU O              )                                                      MAKE CHECK OR MONEY ORDER
                                                                                       20. TOTAL DUE AND PAYABLE:                        PAYABLE TO
4.    TOTAL CITY NET TAXABLE SALES & SERVICE       LINE 2B MINUS                                                                  CITY OF GRAND JUNCTION
                                                   ( TOTAL LINE 3            )                                              (                                            )
                                            PLEASE COMPLETE THIS FORM ON REVERSE SIDE

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SALES/USE
    TAX
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                                                                BE SURE TO REVERSE CARBON BEFORE FILLING OUT THESE SCHEDULES

                               SCHEDULE B - CITY USE TAX
The Use Tax Ordinance imposes a tax upon the privilege of using, storing, distributing or otherwise consuming
tangible personal property purchased, rented or leased.

DATE OF      NAME OF VENDOR                            TYPE OF COMMODITY                     PURCHASE                                                        ADD:  EXCESS TAX COLLECTED  
PURCHASE               ADDRESS                         PURCHASED                             PRICE

  (A)  LIST OF PURCHASES (IF ADDITIONAL SPACE NEEDED - ATTACH SCHEDULE IN SAME FORMAT)                                                     SPECIAL MESSAGE TO AND FROM CITY/TAXPAYER

                                                                                      $

  (B)  TOTAL PURCHASE PRICE OF PROPERTY SUBJECT TO CITY USE TAX                       $
     ENTER TOTAL LINE (B) ON LINE 15 FRONT OF RETURN

     NEW BUSINESS DATE                                                                                   SHOW BELOW CHANGE OF OWNERSHIP, NAME AND/OR         I hereby certify, under penalty of perjury, that the statements made
                                                                                                         ADDRESS, ETC.                                       herein are to the best of my knowledge true and correct.
     MO  DAY YR
                               1. If ownership has changed, give date of change and new owner's name.
                               2. If business has been permanently discontinued, give date discontinued.    _____________________________________            BY _____________________________________________________
                               3. If business location has changed, give new address.
     DISCONTINUED DATE         4. Records are kept at what address?                                         _____________________________________            COMPANY _______________________________________________
                               5. If business is temporarily closed, give dates to be closed.
     MO  DAY YR                6. If business is seasonal, give months of operation.                        _____________________________________            PHONE __________________________________________________
                       {
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                                                                                                             o BUS. ADDRESS                o MAILING ADDRESS               TITLE                          DATE