Form 21943 - Audit Billback Form
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1The North Dakota sales tax law requires retailers to add the sales tax to the sales price, and collect it from the customer. State
law further states the sales tax is a legal debt of the consumer or user to the retailer until paid (North Dakota Century Code
§ 57-39.2-08.2). A fi eld auditor of the North Dakota Sales and Use Tax Section has recently completed an audit of our records
and has determined that the North Dakota sales tax was not collected from you on the following sales, therefore, we are billing
you back as indicated below.
Invoice Date
Invoice No.
Amount of Sale
Invoice Date
Invoice No.
Amount of Sale
_____________________________________________
_______________________________________________
_____________________________________________
_______________________________________________
_____________________________________________
_______________________________________________
_____________________________________________
_______________________________________________
_____________________________________________
_______________________________________________
_____________________________________________
_______________________________________________
Total Sales Per Invoice
X
Tax Rate
=
Sales/Use Tax Due
$__________________
3%
$ __________________
$__________________
4%
$ __________________
$__________________
5%
$ __________________
$__________________
5½%
$ __________________
$__________________
6%
$ __________________
$__________________
____%
$ __________________
$__________________
____%
$ __________________
Total Due
$ __________________
Your cooperation in settling this matter promptly is greatly appreciated.
Sincerely,
To be completed by CUSTOMER:
❏
Enclosed is our payment for the amount of tax due.
❏
Include tax on all future invoices.
If tax has been paid directly to the North Dakota Offi ce of State Tax Commissioner or is not due, please explain
below:
❏
We have made payment directly to the State under permit number _____________________ and relieve you
of the liability for collection.
❏
We are a tax exempt organization as allowed under North Dakota sales/use tax law. Our North Dakota sales
tax exemption number is _________________________________.
❏
I am in the business of buying, selling, leasing, ____________________ and items purchased are for resale.
I will assume total responsibility for all taxes and penalties due. My permit number is _________________.
Signed______________________________________
Date _______________________
21943
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