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___________________________ ______________________ __________________ ______
PUBLIC SERVICE TAX ON PURCHASE OF METERED OR BOTTLED GAS
(NATURAL, LIQUEFIED PETROLEUM GAS OR MANUFACTURED
)
For the Month of 20
LEVIED BY THE BOARD OF COUNTY COMMISSIONERS OF
PALM
BEACH COUNTY, FLORIDA ORDINANCE NO 89-13
TOTAL SALES TO ALL CUSTOMERS:
1. Gross sales for gas products for month (Sales info is required) $
2. Less Exempt sales (as defined by Statute/Ordinance) $ ( )
3. Total N et Sales (line 1 minus line 2) $
TOTAL NET SALES TO ONETIME PURCHASERS:
4. Total N et S ales taxed at 10% (.10 times Total Net Sales from line 3) $
*THE FOLLOWING CALCULATIONS SHOULD BE USED ONLY IF AN INDIVIDUAL MONTHLY BILLED
CUSTOMER EXCEEDS $4000.00 IN MONTHLY PURCHASES.
*TOTAL NET SALES TO ONLY THOSE CUSTOMERS THAT ARE BILLED MONTHLY:
5. Total N et s ales taxed at 10%*
(.10 ti
mes first $4,000 of sales to
Individual Customer Billed Monthly) $
6. Total N et sales taxed at 2%*
(.02 ti
mes next $2,000 of sales to
Individual Customer Billed Monthly) $
7. Total N et sales taxed at 1%*
(.01 ti
mes all sales over $6,000 to
Individual Customer Billed Monthly) $
8. Total amount of Public Service Tax collected and remitted
(Add
lines 4 through 7) $
By checking this box I declare that the business listed below experienced no taxable sales during the reporting month
referenced above.
Reason for zero dollar report: ___________________________________________________________________________
I certify to the accuracy of this report:
Name of Company
S
treet Address
/Store #, City/State, Zip
Telephone/Email
Pri
nt
Authorized
Nam
e
Authorized Signature Title
Date
>>>
PLEASE MAKE CHECKS PAYABLE TO
THE “B
OARD OF COUNTY COMMISSIONERS”<<<
Completed remittance forms along with your payment should be mailed to the following address: Finance Department,
Clerk of the Circuit
Court
& Comptroller, Palm Beach County, P.O. Box 3977, West Palm Beach, Florida 33402.
Completed remittance forms and payments must be received in the Finance Department no later than the 15
th
day of the
th
month
following the month in which the tax was collected.
Payments received after the 15
day of the month are subject
to interest and penalty charges.
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signature
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