Monthly Report - Prepared Food And Beverage Form - Virginia Commissioner Of The Revenue

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ANN H. THOMAS
File & pay online at IT’S
COMMISSIONER OF THE REVENUE
elect “E Commissioner Online”
CONVENIENT, EASY AND SECURE! S
COUNTY OF YORK
then select “Prepared Food and Beverages Tax Monthly Online Filing”.
P.O. BOX 189
A window will open to file online. To easily access your account, use the
YORKTOWN, VA 23690-0189
Account No. located on this form.
(757) 890-3383
MONTHLY REPORT - PREPARED FOOD AND BEVERAGE
FORMS WILL NOT BE MAILED EACH MONTH.
Due to budgetary constraints and the ease of the online filing option, this will be the only form mailed. If you decide
not to use the online filing option, make a copy for each month and fill in the Month and Year on Line 1.
VERIFY ALL PRE-PRINTED INFORMATION AND LINE THROUGH INCORRECT INFORMATION AND PRINT THE CORRECT INFORMATION
Account No.
Business License Account No:
.
Business ID No
Name and Mailing Address
Trade Name and Business Address
Business Phone:
Email Address:
1
GROSS RECEIPTS FOR THE MONTH OF __________________ YEAR ________________
$
2
LESS ALLOWABLE DEDUCTIONS (ATTACH LIST)
$
3
BALANCE OF TAXABLE GROSS RECEIPTS (Line 1 less Line 2)
$
4
TAX: 4% of Line 3
$
PENALTY IF LATE FILING: 10% of Line 4 – (10% or $10.00 whichever is greater but not to exceed the
5
$
amount of tax on Line 4)
6
TOTAL TAX AND LATE FILING PENALTY (Line 4 + Line 5)
$
7
INTEREST - Multiply Line 6 by .00833 for each month late beginning with this month. (Annual Rate of 10%)
$
TOTAL AMOUNT DUE: SUM of Line 6 + Line 7
8
$
MAKE CHECKS PAYABLE TO: TREASURER – YORK COUNTY
th
on or before the 20
of the month following the month being reported to the
RETURN ALONG WITH PAYMENT
Commissioner of the Revenue at the address above.
Make a copy to keep for your records
This tax is held in trust until remitted to the County. In accordance with the state code § 58.1-3906 and § 58.1-3907 unless otherwise described,
the owner, corporate officer or employee, or member or employee of a general partnership or limited liability company shall in addition to other
penalties provided by law, be guilty of a Class 1 misdemeanor for failure to collect and remit these taxes. The wrongful and fraudulent use of
such collections shall constitute embezzlement pursuant to § 18.2-111.
OATH, I the undersigned applicant do swear (or affirm), that the foregoing figures and statements are true, full and correct to the best of my
knowledge and belief for the period stated.
_____________________________________________
_______________________________________
______________________
SIGNATURE OF PERSON AUTHORIZED TO FILE
TITLE
DATE
_________________________________________________________________________
___________________________________
AUTHORIZED PERSON’S MAILING ADDRESS
Phone Number
Ext.
__________________________________________________________________________
___________________________________
E-MAIL ADDRESS
Fax Number
If you would like this office to be able to discuss this return with anyone other than the owner or corporate officer of the business, please check
the box below and provide the authorized person or company.
I authorize the Commissioner of the Revenue’s office to discuss this return with ________________________________.
Revised 1/24/2013

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