Form Rev 86 0058e - Leasehold Excise Tax Return

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October - November - December
Washington State
Department Of Revenue
Q4
11
Leasehold Excise Tax Return
Special Programs Division
PO Box 47464
Publicly Owned Property
Olympia, WA 98504-7464
TAX REG NO.
BUSINESS NAME
STREET ADDRESS
CITY, STATE, ZIP
Taxpayers Must File a Return Even if No Tax is Due.
Attach tax remittance payable to the Washington State Department of Revenue. Should assistance be necessary, write to the Department of
Revenue or call (360) 570-3265 option 4.
Important: If you are a new filer or need additional information on Leasehold Excise Tax please visit our website at:
Location
Tax Due 12.84%
Product Lessee Name
Tax Code Area**
Code
Taxable Rent Due
Less 4.24% Credit
(On Back)
(.0860 X Taxable Rent)
Product leases (leases for users in
production of agriculture or marine
products to the extent that such leases
provide for rent to be paid by the delivery
of a stated percentage of the production
of such products or the proceeds from
the sale of such products).
Regular Lessee Name
Location
Tax Due 12.84%
Standard Leases
Tax Code Area**
Code
Taxable Rent Due
(.1284 X Taxable Rent)
(On Back)
Other Than Product Leases
Subtotal
** Tax Code Area are obtained from your county assessor.
DUE DATE: January 31, 2012
Totals
* 5% Penalty Assessed After January 31, 2012
15% Penalty Assessed After February 29, 2012
25% Penalty Assessed After April 2, 2012
Tax Due
If the due date falls on a weekend or legal holiday,
the due date is extended to the next business day.
* Add Penalty, if Applicable
(Minimum $ 5.00)
%
4
Signature
Total Amount Due
/
/
Phone Number (
)
Date
4
For tax assistance or to request this document in an alternate format, visit
or call 1-800-647-7706. Teletype (TTY) users may call (360) 705-6718.
REV 86 0058e
(11/2/11)

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