Business Name: Federal ID No.:
OFFICE OF TOWN TREASURER
TOWN OF CULPEPER
400 South Main Street, Ste. 109
540-829-8240
MONTHLY REMITTANCE OF ADMISSIONS TAX
1. Gross admissions tax collected for the month of ______________, 20____ $
2. LESS allowable deductions (attach list) $
3. Balance taxable $
4. 5% tax on item #3 (amount due)
$
5. Penalty for late payment – 10% of item #4 $
6. Total tax and penalty (total lines 4 and 5) $
7. 10% per annum interest on tax and penalty $
8. Total tax, penalty and interest due and paid herewith $
MAKE CHECK PAYABLE TO TOWN OF CULPEPER
DECLARATION OF COLLECTOR:
I hereby swear or affirm the amounts listed above are true, correct and
complete to the best of my knowledge and belief for the period stated.
Date _________________________ Signed By: _____________________________
Phone No._____________________ Title: __________________________________
INSTRUCTIONS: Mail original and second copy to the Town Treasurer on or before the 20
th
of the
month following the month being reported at: Town of Culpeper
Town Treasurer
400 South Main Street, Ste 109
Culpeper, VA 22701
For Office Use:
______________________ ________________________
Date Received in Office Receipt Number
