Sd Eform 0872 - Coin Operated Washer And Dryer License Application

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Date Received________________

SD EForm - 0872

Approved___________________

Date Issued__________________

COIN OPERATED WASHER AND DRYER LICENSE APPLICATION

(Separate application needed for each location)

Revenue, Special Tax Division, 445

Capitol Ave, Pierre South Dakota 5750l

MAIL TO: Department of

Owner's Name and Address:

Business Name and Address:

New

License Number

Renewal

Owner's Telephone Number _________________________

Manager's Telephone Number _________________________

Coin operated washers and dryers are charged an annual fee of $16.00 per unit in a city under 1,000 population and $20.00 per unit for each machine in a

city over 1,000 population or if located outside the corporate limits of a city. Application for the calendar year license is due and payable prior to

January 1, annually. (Additional sheets maybe attached). Persons failing to file by December 31st of the year prior to the year for which the fee is due

will be assessed interest at the rate of 1.25% per month or fraction thereof and penalty equal to 10% of the tax due or $10.00 whichever is greater.

Notice: Failure to apply for a license and display such license subjects the operator or manager to a fine of $100.00 or 30 days in jail or both.

Make

Serial Number

Address

Units

The above units are located within the city of ______________________or located outside and near the city of ____________________.

(Fill in applicable space)

0.00

Total Number of $16.00 Units ___________________________ Amount $ _________________________________________

0.00

Total Number of $20.00 Units __________________________