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CITY OF BURLINGTON ADMISSIONS TAX QUARTERLY REPORT FORM For Quarter Ending Business Name/Address Number of Admissions Sold Gross Admissions Receipts x Tax Rate of 5% = ADMISSIONS TAX PAYABLE Enclosed is payment in full for the tax payable as calculated above. I certify that the Information provided herein is accurate. Owner/Lessee/Premise Custodian In order to avoid a late penalty, this form along with remittance must be received by the last day of month next succeeding the end of the quarter period in which the tax is collected (last day of April, July, October, and January). Mailing Address: Burlington City Hall 833 S. Spruce Street Burlington, WA 98233