TOWN OF CULPEPER
400 South Main Street, Ste. 109
540-829-8240
Due on or before the 20
th
of each month following month for which report is made.
Business Name: Federal ID No.: ________
Owner Name: Customer No.: ________
MONTHLY REMITTANCE OF MEALS TAX
1. Gross receipts for the month of ___________________, 20________
$
2. LESS allowable deductions
(attach required list) . . . . . . . . . . . . $
3. Balance taxable . .
(line 1 – line 2) . . . . . . . . . . . . . . . . . . $
4.
6% tax on item 3 . . . . .(.06 x line 3). . . . . . . . . . . . . . . . . $
5. LESS 3% discount on item 4
(.03 x line 4 if paid by 20
th
of month due) . $
6. Balance—total tax less sellers discount . . . . . . . . . . . . . . . .
$
7. Penalty for late payment—10% of item 4
(.10 x line 4) . . . . . . . . . $
8. Total tax and late payment penalty
(line 6 + line 7) . . . . . . . . . . $
9. 10% per annum interest on tax and penalty . . . . . . . . . . . . . .
$
(Line 8 x .10 ÷ 365 x number of days late)
10. TOTAL TAX, PENALTY AND INTEREST . . . . . . . . . . . . . . . . . $
______________________________________________________________________________________________
Please remit the amount shown on Line 10 to: Treasurer, Town of Culpeper
400 South Main Street, Culpeper VA 22701
IF PAID AFTER THE DUE DATE A PENALTY OF 10% OF THE TAX AND INTEREST AT THE RATE OF 10% PER ANNUM WILL BE
COMPUTED AND DUE AND PAYABLE IN ACCORDANCE WITH SECTIONS 23-70 AND 23-72 OF THE TOWN CODE.
______________________________________________________________________________________________
DECLARATION OF SELLER:
I hereby swear or affirm that the amounts listed above are true, correct, and complete to the best of my knowledge and
belief for the period stated above.
Date ___________________ Signature _______________________________________
PRINT NAME___________________________________
Phone No. _____________________ Title ___________________________________________
============================================================================================
Office use only:
Received by Treasurer’s Office: Amount paid: ________________ Date: _________ Postmark Date: ______________ Initial: _________
Refunded/adjusted amount: ____________________ Adjusted Total Tax, Penalty and Interest: ________________________
Clerk’s Office validation: Date: _______________________ Initial: ______________
Rev. Aug 2015
