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Name*	Filing Month*/Year * --- Month --- January February March April May June July August September October November December --- Year --- 2011 2010 2009 2008
Trade Name *	Due Date* dd/mm/yyyy
Mailing Address *	Filing Date* dd/mm/yyyy
City*
State*
Zip Code*
Definite Location of business*

1. Gross receipts*	$ (1.)
2. Allowable deductions: a. Meals to employees when no charge is made to employee $ (2a.) b. Meals paid for by Federal, State, or Local Governments. $ (2b.) c. Meals or food sold from coin operated vending machines $ (2c.) d. Other (please state) $ (2d.) e. Total Deductions $ (2e.)
3. Item 1 less 2(e)	$ (3.)
4. Tax (6% of Item 3)	$ (4.)
5. Seller's discount (3% of item 4)	$ (5.)
6. Total Tax less Seller's Discount (item 4 less item 5)	$ (6.)
7. Penalty for late payment (5% of item 4 minimum $2.00	$ (7.)
8. Interest (10% per Annum)	$ (8.)
9. Total tax, penalty and interest (sum 6,7,8)	$ (9.)
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