City of Central

Phone: 303-582-5251

c/o Finance Department

PO Box 249

Central City, CO 80427

Name of Business:

Company Name: (If Different)

Physical Address:

Mailing Address: (If Different)

Account #:____________________________

Report Period: Month______________ Year__________

City Sales Tax 4% General of Line 5

Amount of Line 5 Subject to Lodger's Tax $___________x 3%

Excess Tax Collected

Adjusted City Tax (Add lines 6A, 6B &7)

City Sales Tax 2% Public Safety of Line 5

C. Sales Shipped out of City

TOTAL SALES TAX (Add lines 9 and 11)

Use Tax Due (From Schedule B Below)

Amount of Line 5 Subject to Marijuana Tax $__________x 5%

G. Government, Religious Charitable

TOTAL TAX DUE (Add lines 12, 13 and 14)

Penalty 10% of Total line 15 if late

Interest 1%/ month of Total line 15 if late

TOTAL TAX, PENALTY & INTEREST

Total Deductions (Add lines A-J)

Net Taxable (line 2B minus line 4)

TOTAL DUE & PAYABLE >>>>>>>>>>>>>>

Type of Commodity Purchased

Total purchase price of property/service subject to City Use Tax >>>>>>>>>>>>>>

>>>>>>

Use Second Sheet if Necessary

Use Tax Due: Multiply total by 4% General>>>>>>>>>>>>

Use Tax Due: Multiply total by 2% Public Safety>>>>>>>>>>>>

I declare under penalty of perjury that the information contained on this form is true and correct to the best of my knowledge.

Signature:___________________________________________

Date:_____________________

Title:_______________________________________________

Phone:____________________