Forms Center • Dinwiddie County, VA • CivicEngage

Basic Information

1. Gross Receipts for the Month Of:
2. Less Allowable Deductions
Attach list
Allowable Deductions List
3. Balance Taxable
4. 4% Tax on Ammount from #3
5. Less 3% Sellers Discount of Item #4
Only when filed on time
6. Balance - Total Tax Less Sellers Discount
7. Penalty for Late Payment
Note: 6% penalty to be added for the first 30 days that account is postmarked after the due date, an additional 6% penalty to be added for each additional 30 days that account continues to be late; penalty not to exceed 30%. minimum penalty is $10.
8. Total - Tax and Penalty
9. Total - Tax and Penalty Due and Paid Herewith
Continue |Go Back

I Agree To the Below Statement
1. Yes
1. No
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.
First Name
Last Name
Telephone Number
Title

Leave This Blank: