Fillable Form 166 Withholding Assessment Fee: GOVERNMENT OF GUAM (Guam Department of Revenue & Taxation)

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Form 166 Withholding Assessment Fee: GOVERNMENT OF GUAM (Guam Department of Revenue & Taxation)

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Form 166 Withholding Assessment Fee
Pursuant to §71114, Chapter 71 of Division 3, Title 11, Guam Code Annotated (GCA). A with-
holding assessment fee for a non-resident person/entity shall be assessed four percent (4%)
on contracts awarded by the Government of Guam for professional services. [P.L. 33-166]
Name and Address of Vendor:
Government Agency Name and Address:
Description of Contract:
Awarded Date of Contract:
Awarded Contract Amount:
(4%) Withholding Fee:
Under the penalties of perjury , I declare that I have examined this form, and to the best of my
knowledge and belief it is true, correct and complete.
Signature of Authorized Signature of Authorized
Government Representative Vendor
Date: Date:
DEPARTMENT OF REVENUE AND TAXATION
Dipåttamenton Kontribusion yan Adu’ånå
GOVERNMENT OF GUAM
Gubetnamenton Guåhan
Original
Amended
FOR OFFICIAL USE ONLY
Reference Number:
Contact No.:
Contact No.:
Name of Agency Representative:
Form 166 (0319v1)
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Form 166 Withholding Assessment Fee: GOVERNMENT OF GUAM (Guam Department of Revenue & Taxation)

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Completed 22 June 2021

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