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Name*	Filing Month*/Year * --- Month --- January February March April May June July August September October November December --- Year --- 2012 2011 2010 2009 2008
Trade Name *	Due Date* mm/dd/yyyy
Mailing Address *	Filing Date* mm/dd/yyyy
City*
State*
Zip Code*
Definite Location of business*

1. Gross rentals*	$ (1.)
2. Allowable deductions: a. Exempt rentals (over 30 days) $ (1a.) b. Refund of Rentals included in line 1 of this report $ (1b.) c. Refund of rentals included in prior reports $ (1c.) d. Total deductions $ (1d.)
3. Item 1 less 2(d)	$ (3.)
4. Tax (6% of Item 3)	$ (4.)
5. Penalty for late payment (5% of item 4 or minimum of $2.00)	$ (5.)
6. Interest (10% Annum)	$ (6.)
7. Total tax, penalty and interest ( sum of items 4, 5, 6)	$ (7.)
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