Form 04-578 - Alaska Seafood Marketing Assessment 2005
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12005 Alaska Seafood Marketing Assessment
Department of Revenue
DEPT USE ONLY
Tax Division
FORM 04-578
PO Box 110420
Envelope #
Juneau, Alaska 99811-0420
Telephone (907)465-2320
Fax (907)465-3566
FSN
Due: March 31, 2006
Federal EIN or SSN
Telephone Number
Fax Number
Individual or Corporation Name
E-mail Address
Business Name
Contact Person
Title
Mailing Address
Check if:
Bonus
Month
Amended (attach explanation)
Year
City
State
Zip Code
Make checks payable to:
Alaska Department of Revenue
A. Fisheries
C. Value of Seafood Products (from
Bus. Lic No.
B. Facility Location or Vessel Name
each Fisheries Tax Return)
1. Total value of seafood products listed in column C. (If less than $50,000,
skip line 2 , sign the return, and file it on or before the due date)………………………… …
1
2. Assessment. Multiply the value on line 1 by .5% (.005)…………………………………… …
(This is your Seafood Marketing Assessment, please remit payment )
2
Note: If your liability exceeds $150,000, you must use Electronic Funds Transfer (TOPS) or wire transfer funds.
Check if you are remitting by:
Wire Transfer
TOPS Confirmation Number____________________________________________ _
I declare under penalty of unsworn falsification that the information provided in this return has been reviewed by me, and to t he
best of my knowledge and belief is true, correct, and complete. If prepared by a person other than the taxpayer, preparer's
declaration is based on all information of which preparer has any knowledge.
Signature
Type or Print Name
Date
DEPARTMENT USE ONLY
VALIDATION
PMD:
Form 04-578 (Rev 12/05)
Page 17
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