Remittance Of Collected Consumer Utility Taxes Form - County Of Fauquier, Virginia

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County of Fauquier, Virginia
Remittance of Collected Consumer Utility Taxes
Section A: Business Information
Federal Employer Identification Number (FEIN):
__ __ - __ __ __ __ __ __ __
Full Legal Name of Business:
______________________________________________
Complete Mailing Address:
______________________________________________
______________________________________________
Section B: Tax Type and Collection Period
Month and Year Tax was Collected:
__________
__________
Month
Year
‫ ڤ‬Telephone
‫ ڤ‬Mobile Phone
‫ ڤ‬E911
‫ ڤ‬Electric
‫ ڤ‬Natural Gas
Section C: Tax Collected
Total Tax Billed Subscribers
______________________
Deductions (please itemize)
______________________
______________________
______________________
______________________
Additions (please itemize)
______________________
______________________
______________________
______________________
Total Tax Due:
______________________
Section D: Due Date and Filing Information
Remit To:
Make Check Payable To:
Commissioner of the Revenue
Treasurer, Fauquier County
P.O. Box 149
Warrenton, VA 20188
Payment must be postmarked on or before
the last day of the calendar month following the
month for which the tax was collected
Section E: Signature
This form must be signed by an officer of the corporation, or member of the partnership or
limited liability company, who is authorized to sign on behalf of the organization.
_______________________________ ________________________________
Name
Title
_______________________________ _______________
_____________
Signature
Date
Phone

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