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SS WHERE PROPERTY IS USED ( STATE ZIP CODE q same as above) BRIEF DESCRIPTION OF ITEM PURCHASED (attach a separate sheet if more space is needed) PURCHASE DATE PURCHASE PRICE $ $ $ $ $ $ $ TOTAL PURCHASES FOR THE CALENDAR YEAR $ TAX RATE x USE TAX SUBTOTAL $ DEDUCT SALES TAX PAID TO ANOTHER STATE $ NET USE TAX DUE $ ADD 10% PENALTY IF APPLICABLE (see instructions) $ ADD INTEREST IF APPLICABLE (see instructions) $ TOTAL DUE $ SIGNATURE DATE PRINT NAME DAYTIME TELEPHONE ( ) Write you.

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