TAXPAYER’S NAME AND ADDRESS
 PERIOD                                                                                               ACCOUNT                                                                    CITY OF GREELEY
 COVERED                                                                                              NUMBER                                                                        SALES/USE TAX RETURN
 DUE                                                                                                                                                                                PO Box 1648   .Greeley, CO 80632
 DATE                                                                                                                                                                            PHONE: (970) 350-9733  FAX: (970) 350-9736
                                                                                                                                                                                 EMAIL: greeleysalestax@greeleygov.com
                                                                                                                                                                                        COMPUTATION OF TAX
                                                                                                                                           5. AMOUNT OF CITY SALES TAX: (LINE 4) $_____________X .0411=
                                                                                                                                           6. AMOUNT OF FOOD TAX: (LINE 3M) $_____________X .0346=
                                                                                                                                           7. ADD: EXCESS TAX COLLECTED:
                                                                                                                                           8. ADJUSTED CITY TAX: (SUM OF LINES 5,6 AND 7)
    GROSS SALES                                  TOTAL RECEIPTS FROM CITY ACTIVITY MUST BEREPORTED AND ACCOUNTED FOR IN EVERY RETURN INCL.
1.  AND SERVICE                      ( ALLBOTHSALES,TAXABLERENTALS,AND NON-TAXABLE.AND LEASES AND ALL SERVICES   )                         9.                                                                                          XXXX XX
2A. ADD: BAD DEBTS COLLECTED                                                                                                               10.                                                                                         XXXX XX
2B. TOTAL: (SUM OF LINES 1 AND 2A)                                                                                                         11. CITY USE TAX: (SCHEDULE B) $_____________X .0411=
3.  A.NON-TAXABLE      SERVICE SALES (INCLUDED IN ITEM 1 ABOVE)                                                                            12. TOTAL TAX DUE: (ADD LINES 8 AND 11)
                                                                                                                                                     LATE FILING                    A - PENALTY: (LINE 12 x .10) =                     13A+13B
    B. SALES TO OTHER LICENSED DEALERSFOR PURPOSES OF TAXABLE RESALE                                                                       13. IF RETURN IS FILED               ADD:
    C.CITYSALESAND/ORSHIPPEDSTATE             OUT OF      (           ITEMINCLUDED1 ABOVEIN)                                                   (            AFTER DUE DATE THEN )   B - INTEREST: (LINE 12 x .01 x # OF MONTHS LATE) =
    D.CHARGEDBAD DEBTS            OFF          (                  ONTAXWHICHHASCITYBEENSALESPAID)                                          14. TOTAL TAX, PENALTY AND INTEREST DUE: (ADD LINES 12 AND 13)
                                                                                                                                                                                                                                       15A-15B
D   E. TRADE-INS FOR TAXABLE RESALE                                                                                                        15. ADJUSTMENT PRIOR PERIODS             A - ADD:
E   F. SALES OF GASOLINE AND CIGARETTES                                                                                                                                             B - DEDUCT:
U   G.                                                                                                                                                                           MAKE CHECK OR MONEY ORDER               TOTAL OF
D      SALESAND CHARITABLETO GOVERNMENTAL,ORGANIZATIONSRELIGIOUS                                                                           16.TOTAL DUE AND PAYABLE:                    PAYABLE TO                      LINES 14 AND 15
C   H.RETURNED GOODS                                                                                                                                                             (                 CITY OF GREELEY      )
T
O
I   I. PRESCRIPTION DRUGS /PROSTHETICDEVICES                                                                                                                     SPECIAL MESSAGE TO AND FROM CITY/TAXPAYER
N   J. OTHER DEDUCTIONS LIST
S                                                                                                                                          ____ CHECK HERE FOR BUSINESS CLOSURE / CHANGE OF OWNERSHIP
    K.                                                                                                                                     ____ CHECK HERE IF CHANGE OF ADDRESS
    L.                                                                                                                                     COMPLETE THE REVERSE SIDE IF ANY OF THE ABOVE APPLY
    M. TAXABLE FOOD SALES
                                                                                                                                                                 PLEASE COMPLETE THIS FORM ON REVERSE SIDE
    3. TOTAL DEDUCTIONS                                                      (              TOTALA THRUOF LINESM)
4. TOTAL CITY NET TAXABLE SALES & SERVICE                                                             (           LINETOTAL2B MINUSLINE 3 )                        *** ALWAYS SIGN REVERSE SIDE OF FORM ***

                                                          TAXPAYER’S NAME AND ADDRESS
 PERIOD                                                                                               ACCOUNT                                                                    CITY OF GREELEY
 COVERED                                                                                              NUMBER                                                                        SALES/USE TAX RETURN
 DUE                                                                                                                                                                                PO Box 1648   .Greeley, CO 80632
 DATE                                                                                                                                                                            PHONE: (970) 350-9733  FAX: (970) 350-9736
                                                                                                                                                                                 EMAIL: greeleysalestax@greeleygov.com
                                                                                                                                                                                        COMPUTATION OF TAX
                                                                                                                                           5. AMOUNT OF CITY SALES TAX: (LINE 4) $_____________X .0411=
                                                                                                                                           6. AMOUNT OF FOOD TAX: (LINE 3M) $_____________X .0346=
                                                                                                                                           7. ADD: EXCESS TAX COLLECTED:
                                                                                                                                           8. ADJUSTED CITY TAX: (SUM OF LINES 5,6 AND 7)
    GROSS SALES                                  TOTAL RECEIPTS FROM CITY ACTIVITY MUST BEREPORTED AND ACCOUNTED FOR IN EVERY RETURN INCL.
1.  AND SERVICE                      ( ALLBOTHSALES,TAXABLERENTALS,AND NON-TAXABLE.AND LEASES AND ALL SERVICES   )                         9.                                                                                          XXXX XX
2A. ADD: BAD DEBTS COLLECTED                                                                                                               10.                                                                                         XXXX XX
2B. TOTAL: (SUM OF LINES 1 AND 2A)                                                                                                         11. CITY USE TAX: (SCHEDULE B) $_____________X .0411=
3.  A.NON-TAXABLE      SERVICE SALES (INCLUDED IN ITEM 1 ABOVE)                                                                            12. TOTAL TAX DUE: (ADD LINES 8 AND 11)
                                                                                                                                                     LATE FILING                    A - PENALTY: (LINE 12 x .10) =                     13A+13B
    B. SALES TO OTHER LICENSED DEALERSFOR PURPOSES OF TAXABLE RESALE                                                                       13. IF RETURN IS FILED               ADD:
    C.CITYSALESAND/ORSHIPPEDSTATE             OUT OF      (           ITEMINCLUDED1 ABOVEIN)                                                   (            AFTER DUE DATE THEN )   B - INTEREST: (LINE 12 x .01 x # OF MONTHS LATE) =
    D.CHARGEDBAD DEBTS            OFF          (                  ONTAXWHICHHASCITYBEENSALESPAID)                                          14. TOTAL TAX, PENALTY AND INTEREST DUE: (ADD LINES 12 AND 13)
                                                                                                                                                                                                                                       15A-15B
D   E. TRADE-INS FOR TAXABLE RESALE                                                                                                        15. ADJUSTMENT PRIOR PERIODS             A - ADD:
E   F. SALES OF GASOLINE AND CIGARETTES                                                                                                                                             B - DEDUCT:
U   G.                                                                                                                                                                           MAKE CHECK OR MONEY ORDER               TOTAL OF
D      SALESAND CHARITABLETO GOVERNMENTAL,ORGANIZATIONSRELIGIOUS                                                                           16.TOTAL DUE AND PAYABLE:                    PAYABLE TO                      LINES 14 AND 15
C   H.RETURNED GOODS                                                                                                                                                             (                 CITY OF GREELEY      )
T
O
I   I. PRESCRIPTION DRUGS /PROSTHETICDEVICES                                                                                                                     SPECIAL MESSAGE TO AND FROM CITY/TAXPAYER
N   J. OTHER DEDUCTIONS LIST
S                                                                                                                                          ____ CHECK HERE FOR BUSINESS CLOSURE / CHANGE OF OWNERSHIP
    K.                                                                                                                                     ____ CHECK HERE IF CHANGE OF ADDRESS
    L.                                                                                                                                     COMPLETE THE REVERSE SIDE IF ANY OF THE ABOVE APPLY
    M. TAXABLE FOOD SALES
                                                                                                                                                                 PLEASE COMPLETE THIS FORM ON REVERSE SIDE
    3. TOTAL DEDUCTIONS                                                      (              TOTALA THRUOF LINESM)
4. TOTAL CITY NET TAXABLE SALES & SERVICE                                                             (           LINETOTAL2B MINUSLINE 3 )                        *** ALWAYS SIGN REVERSE SIDE OF FORM ***

                     SCHEDULE - B - CITY USE TAX                                                           SCHEDULE - C - CONSOLIDATED ACCOUNTS REPORT
                                                                                               This schedule is required in all cases in which the taxpayer makes a consolidated return which includes
The Greeley Municipal Code imposes a tax upon the privilege of using, storing, distributing or sales made at more than one location. It must be completely filled out and convey all information
consuming in the City tangible property or taxable services purchased, rented or leased.       required in accordance with the column headings.If additional space is needed attach schedule in same
                                                                                               format.
DATE OF      NAME OF VENDOR TYPE OF COMMODITY                                       PURCHASE   ACCOUNT     BUSINESS ADDRESSES                PERIODS TOTAL GROSS    PERIODS NET TAXABLE
PURCHASE     ADDRESS        PURCHASED                                               PRICE      NUMBER      OF CONSOLIDATED ACCOUNTS          SALES (AGGREGATE TO    SALES (AGGREGATE TO
                                                                                                                                           LINE 1 FRONT OF RETURN) LINE 4 FRONT OF RETURN)
(A) LIST OF PURCHASES (IF ADDITIONAL SPACE NEEDED-ATTACH SCHEDULE IN SAME FORMAT)                                                          $                       $
                                                                            $

(B) TOTAL PURCHASE PRICE OF PROPERTY SUBJECT TO CITY USE TAX
        ENTER TOTAL LINE (B) ON LINE 11 ON FRONT OF RETURN
                                                                            $                  ENTER TOTALS HERE AND ON FRONT OF RETURN    $                       $

                     1.  If ownership has changed, give date of change and new owner’s name    SHOW BELOW CHANGE OF OWNERSHIP, NAME AND/OR I hereby certify under penalty of perjury, that the statements
NEW BUSINESS DATE    2.  If business has been permanently discontinued, give date discontinued ADDRESS.                                    made herein are to the best of my knowledge, true and correct.
MO.      DAY YR.     3.  If business location has changed, give new address                                                                BY
                     4.  Records are kept at what address?                                                                                 COMPANY
DISCONTINUED DATE    5.  If business is temporarily closed, give dates to be closed                                                        PHONE
MO.      DAY YR.     6.  If business is seasonal, give month of operation
                     7.  If the return includes sales for more than one location, refer to and
                          complete schedule "C"                                                BUS ADDRESS MAILING ADDRESS                        TITLE             DATE

                     SCHEDULE - B - CITY USE TAX                                                           SCHEDULE - C - CONSOLIDATED ACCOUNTS REPORT
                                                                                               This schedule is required in all cases in which the taxpayer makes a consolidated return which includes
The Greeley Municipal Code imposes a tax upon the privilege of using, storing, distributing or sales made at more than one location. It must be completely filled out and convey all information
consuming in the City tangible property or taxable services purchased, rented or leased.       required in accordance with the column headings.If additional space is needed attach schedule in same
                                                                                               format.
DATE OF      NAME OF VENDOR TYPE OF COMMODITY                                       PURCHASE   ACCOUNT     BUSINESS ADDRESSES                PERIODS TOTAL GROSS    PERIODS NET TAXABLE
PURCHASE     ADDRESS        PURCHASED                                               PRICE      NUMBER      OF CONSOLIDATED ACCOUNTS          SALES (AGGREGATE TO    SALES (AGGREGATE TO
                                                                                                                                           LINE 1 FRONT OF RETURN) LINE 4 FRONT OF RETURN)
(A) LIST OF PURCHASES (IF ADDITIONAL SPACE NEEDED-ATTACH SCHEDULE IN SAME FORMAT)                                                          $                       $
                                                                            $

(B) TOTAL PURCHASE PRICE OF PROPERTY SUBJECT TO CITY USE TAX
        ENTER TOTAL LINE (B) ON LINE 11 ON FRONT OF RETURN
                                                                            $                  ENTER TOTALS HERE AND ON FRONT OF RETURN    $                       $

                     1.  If ownership has changed, give date of change and new owner’s name    SHOW BELOW CHANGE OF OWNERSHIP, NAME AND/OR I hereby certify under penalty of perjury, that the statements
NEW BUSINESS DATE    2.  If business has been permanently discontinued, give date discontinued ADDRESS.                                    made herein are to the best of my knowledge, true and correct.
MO.      DAY YR.     3.  If business location has changed, give new address                                                                BY
                     4.  Records are kept at what address?                                                                                 COMPANY
DISCONTINUED DATE    5.  If business is temporarily closed, give dates to be closed                                                        PHONE
MO.      DAY YR.     6.  If business is seasonal, give month of operation
                     7.  If the return includes sales for more than one location, refer to and
                          complete schedule "C"                                                BUS ADDRESS MAILING ADDRESS                        TITLE             DATE