TENNESSEE DEPARTMENT OF REVENUE REVISED STATE AND LOCAL SALES AND USE TAX RETURN SLS 450 ACCOUNT NO. Filing Period If this is an AMENDED RETURN, please check the box at right LOCATION ADDRESS Due Date } IMPORTANT: Returns must be postmarked by the due date to avoid the assessment of penalty and interest. Returns must be filed even if no sales were made or any tax due. Should you need assistance, please contact the Taxpayer Services Division by calling our statewide number (800)3421003 or (615) 253-0600. Remit amount shown in item 19, payable to: TENNESSEE DEPARTMENT OF REVENUE Andrew Jackson State Office Building 500 Deaderick Street, Nashville, TN 37242 or you may file your return and payment online at www.Tennessee.gov/revenue ROUND TO NEAREST DOLLAR WRITE NUMBERS LIKE THIS 1. GROSS SALES INCLUDING FOOD SALES AND/OR RENTAL PROCEEDS (1) 00 2. ADD COST OF PERSONAL PROPERTY PURCHASED ON A RESALE CERTIFICATE BUT USED BY YOU, INCLUDING GIFTS AND PREMIUMS (2) 00 3. ADD COST OF OUT OF STATE PURCHASES AND PROPERTY IMPORTED INTO TENNESSEE FOR YOUR USE ...................... (3) 00 (4) 00 (5) 00 6. EXEMPT TRANSACTIONS - Must be itemized on Page 2, Schedule A, Line K (6) 00 7. NET TAXABLE TOTAL - STATE - Subtract Line 6 from Line 5 (7) 00 4. FAIR MARKET VALUE OF TANGIBLE PERSONAL PROPERTY FABRICATED, PRODUCED, COMPOUNDED, OR SEVERED FROM THE EARTH FOR USE IN THE STATE OF TENNESSEE 5. TOTAL - Add Lines 1, 2, 3, and 4 8. STATE TAX 9. STATE FOOD TAX 10. LOCAL TAX - 00 % of Line 7............................................................................................................ (8) USE PAGE 2, SCHEDULE B, FOR LOCAL TAX CALCULATIONS ........ YOUR SINGLE % of Line 7 ...ARTICLE TAX BASE IS (9) 00 SEE PAGE 2, SCHEDULE B, IF LOCAL TAXABLE SALES DO NOT EQUAL .. (10) STATE TAXABLE SALES % of Page 2, Schedule A, Line A.......... 00 11. ENTER ANY TAX COLLECTED IN EXCESS OF STATE AND LOCAL LEVIES (11) 00 12. STATE TAX ON TRANSACTIONS SUBJECT TO SINGLE ARTICLE AND REDUCED RATES. ENTER TOTAL TAX FROM PAGE 2, SCHEDULE C, LINE 7 (12) 00 13. LOCAL TAX ON TRANSACTIONS SUBJECT TO THE SPECIAL RATES OF TAX ENTER TOTAL TAX FROM PAGE 2, SCHEDULE C, LINE 10 (13) 00 14. TOTAL TAX - Add Lines 8, 9, 10, 11, 12, and 13 (14) 00 15. ENTER CREDIT MEMO BALANCE ............................................................................................................................................ (15) 00 at 5% to for DELINQUENT { If filed LATE, compute penalty25%.) of the tax (Line 14 minus Line 15) for each 1the 30 DAY PERIODdue which TAX ISthere is any tax(Total (16) penalty NOT TO EXCEED Minimum penalty is $15 regardless of amount of tax or whether due. 00 % per year on the tax (Line 14 minus Line 15) from the due date to the date 17. INTEREST-If filed late, compute interest at of payment.................................................................................................................................................................................................. (17) 00 18. PREPAID WIRELESS E911 fee - 53¢ per retail transaction for prepaid wireless telecommunications less 3% administrative fee.............................................................................................................. (18) 00 19. TOTAL DUE - If filed TIMELY, subtract Line 15 from Line 14 and add Line 18; If filed LATE, subtract Line 15 from Line 14 and add Lines 16, 17, and 18..................................................................................................... (19) 00 16. PENALTY: I declare this is a true, complete, and accurate return to the best of my knowledge. SIGN HERE SIGN HERE FOR OFFICE USE ONLY President or other Principal Officer, Partner or Proprietor Date Tax Return Preparer and Title Date INTERNET (7/11) RV-R0000201 American LegalNet, Inc. www.FormsWorkFlow.com PAGE 1 SCHEDULE A - EXEMPT TRANSACTIONS (See Separate Instructions) (A) 00 (B) 00 (C) 00 D. Sales to the Federal Government, the State of Tennessee and its political Subdivisions, and sales to qualified (D) institutions such as churches, nonprofit schools, hospitals, homes for the aged, and orphanages. 00 A. Food Net Taxable (add to Schedule B, Line 2) B. Sales made to vendors or other establishments for resale, and sales of items to be used in processing articles for sale. (Certificates of Resale must be retained by the Dealer.) C. Sales of items specifically exempt by State Law. E. Returned merchandise -Items voluntarily returned by the purchaser included as sales on this or a previous F. Sales of specifically exempt "Industrial Machinery" and exempt agricultural purchases. G. Sales in Interstate Commerce where the purchaser takes possession outside of Tennessee for use or consumption outside of Tennessee; and sales of motor vehicles and trailers delivered out-of-state by dealers and sales of motor vehicles and boats removed by non-resident customers within three (3) days. H. Repossessions - enter that portion of the unpaid principal balances in excess of $500 due on tangible personal property repossessed from customers. Report the same amount on Schedule B, Line 2. I. Other - Enter deductions not included elsewhere in Schedule A. Include: sales not subject to full state rate such as industrial energy fuel and water, trade-ins, and cash discounts. J. Sales Tax Holiday (first Friday through following Sunday in August) (E) 00 (F) 00 (G) 00 (H) 00 (I) 00 (J) 00 (K) return. Show on Schedule B, Line 2, any amount claimed on Schedule B, Line 4, of prior returns. 00 K. TOTAL - Add lines A through J above. Enter here and on Page 1, Line 6. SCHEDULE B - COMPUTATION OF LOCAL SALES AND USE TAX. NOTE: Use this schedule if Local Taxable Sales do not equal State Taxable Sales. (See Separate Instructions) 1. Enter net taxable total - State - Enter the amount shown on Page 1, Line 7. (1) 00 2. Adjustments (total of Schedule A, Line A and any applicable amounts in Lines E and H above). (2) 00 3. Total - Add Lines 1 and 2. (3) 00 4. Enter all amounts in excess of the single article tax base shown on Page 1, Line 10 of the return on each (4) 00 (5) 00 (6) 00 single article sold or purchased which has been reported, but not deducted elsewhere on the return. 5. Energy Fuel Sales - Enter all energy fuel sales taxed at the full state rate. Do not include sales subject to the reduced rate. See Schedule A, Line I and Schedule C, Line 5. 6. Other - Enter local tax deductions not included in Lines 4 and 5. Include taxable sales of specfied digital products 7. Net taxable total - Local - Add Lines 4, 5, and 6, subtract from Line 3. (7) 00 8. Local sales and use tax - Multiply Line 7 by local tax rate - Enter here and on Page 1, Line 10. (8) 00 subject to 2.5% local tax rate, which are reported on Schedule C, Line 9. SCHEDULE C - COMPUTATION OF STATE SINGLE ARTICLE TAX AND SPECIAL RATES ON ENERGY FUEL, WATER, AND SPECIFIED DIGITAL PRODUCTS (See Separate Instructions) 1. Taxable Single Article Sales from $1,600 to $3,200 (1) 00 2. STATE TAX - 2.75% of Line 1. (2) 00 (3) 00 4. STATE TAX - 1% of Line 3. (4) 00 5. (5) 00 6. STATE TAX - 1.5% of Line 5. (6) 00 7. 3. WATER- Enter sales/purchases of water subject to industrial tax rate. IMPORTANT: See Schedule C, Line 8. ENERGY FUELS - Enter all sales subject to industrial tax rate. (Schedule A, Line I) (7) 00 LOCAL COMPUTATION - Complete this section only if transactions are subject to local tax. 8. WATER - Multiply sales/purchases of water on Schedule C, Line 3 by 1/2 of 1% local industrial tax rate and enter. (8) 00 9. SPECIFIED DIGITAL PRODUCTS - Net taxable sales of specified digital products included in Schedule B, Line 6 ________________________. Multiply by 2.5% and enter here. (9) 00 (10) 00 TOTAL (Add Lines 2, 4, and 6. Enter total here and on Page 1, Line 12). 10. LOCAL TAX - (Add tax calculations from Lines 8 and 9) - Enter here and on Page 1, Line 13, reverse side. Check appropriate box and fill in number: FEIN or SSN If your account number is not preprinted on the front of the return, enter your federal employer identification number (FEIN) or your Social Security number (SSN) in the spaces at left: INTERNET (7/11) American LegalNet, Inc. www.FormsWorkFlow.com PAGE 2