County Name Tax Form

123 Main Street
City, State Zip

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Tax Rate

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Annum Interest Percentage

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Monthly Interest Percentage

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Monthly Penalty Percentage

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Max Penalty Percentage

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Penalty Minimum

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Annual Due Date Offset

15 Days AfterLast Day of Next Month

Choose either 15 days after the selected pay period or the last day of the month after the selected pay period.

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Quarterly Due Date Offset

15 Days AfterLast Day of Next Month

Choose either 15 days after the selected pay period or the last day of the month after the selected pay period.

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Monthly Due Date Offset

15 Days AfterLast Day of Next Month

Choose either 15 days after the selected pay period or the last day of the month after the selected pay period.

Business Name(Required)

Account Number(Required)

Filing Frequency(Required)

Select filing frequencyMonthlyQuarterlyAnnually

Select Quarter(Required)

Select quarterQuarter 1 (Jan – Mar)Quarter 2 (Apr – Jun)Quarter 3 (Jul – Sep)Quarter 4 (Oct – Dec)

Select Month(Required)

Select monthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember

Tax Filing Year(Required)

Due Date(Required)

MM slash DD slash YYYY

Preparer's Name(Required)

First Last

Preparer's Email(Required)

Salaries, Wages, Commissions & Other Compensation(Required)

Adjustment for Exempt Wages(Required)

Taxable Earnings

Total License Fee Due

Months Late

Interest

12% per annum OR 1% monthly

Late Filing Penalty

5% per month, 25% Max, $25 Min

Total Amount Due

Total Amount Due

Price: $0.00

Authorized Signature(Required)

Date Signed(Required)

MM slash DD slash YYYY