Monthly Report of Collections
on Prepared Food and Beverages

Instructions:
This form and payment must be submitted on or before the 20th of the month following the month being reported.

Meals Tax Business I.D. No.     Account No.   
Location Bethel Bruton Grafton Nelson
Business Name (if applicable)  
Last Name (if applicable)       First Name  
Mailing Address
City     State     Zip
Trade Name
Physical Address
City     State     Zip
Business Phone Number    


1. Gross Receipts    for the month of            January February March April May June July August September October November December
2. Less Allowable Deductions (attach list)                           
3. Balance (Taxable)                                                         
4. 4% Tax on Line 3                                                          
5. Penalty for Late Filing (10% of Line 4) $10.00 min.           
6. Penalty for Late Payment (10% of Line 4 & 5) $10.00 min.
7. Interest @ 10% per annum of Line 4, 5, & 6)                    
8. Total Tax, Penalties and Interest (sum of 4, 5, 6, & 7)       


Method of Payment:
On-line (E-check)    (To pay on-line click  here.) 
By mail  (Make checks payable to: Treasurer, County of York) *

*Please Note: If submitting payment by mail, you must enclose a copy of this form as well as fill in the boxes below for the amount of payment enclosed and check #.

Amount of payment enclosed     Check #   
                         
  
Declaration of Seller:
I hereby swear or affirm that the amounts listed above are true, correct and complete to the best of my knowledge and belief for the period stated. By placing your initials in the appropriate box, it will be equivalent to your signature.

Taxpayer Initials     Title     Date

Declaration of Corporate or Partnership Officer:
If this report is being filled on behalf of a corporation or partnership, for purposes of liability for the penalty prescribed by Sec. 58.1-3906, Code of Virginia, for failure to pay the taxes required to be remitted with this report, unless designated otherwise, the president of the corporation, or any general partner in the case of a partnership, hereby accepts liability therefore.
PLEASE INDICATE THE CORPORATE OFFICER OR EMPLOYEE OF A CORPORATION, OR GENERAL PARTNER OR EMPLOYEE OF A PARTNERSHIP WHO IS UNDER THE DUTY TO REMIT TAXES WITH THIS REPORT:

Last Name     First Name
Title
Street Address
City     State     Zip
Phone Number

**This form and payment must be submitted on or before the 20th of the month following the month being reported.**

You may wish to print a copy for your records.

Please verify your information and