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CITY OF KENNEWICK ADMISSIONS TAX RETURN Date: Name/Organization Mailing Address Form of Entertainment Reporting Period From: To: Location of Event Tickets Sold During Reporting Beginning # Ending # Tax on Admissions of eleven cents or more; Send check payable to: one cent on each twenty cents or fraction thereof. CITY OF KENNEWICK PO BOX 6108 ENTER EACH ITEM SEPARATELY KENNEWICK, WA 99336-0108 Gross Number of Total Type of Admission Ticket Net Price Admission Tax Tickets Gross Tax Price per Ticket per Ticket Sold Receipts Due (Column a/1.05) (Column a - b) (Column a x d) (Column c x d) Regular Admissions Complimentary (Include value of ticket) TOTAL SEE REMITTANCE REQUIREMENTS ON REVERSE SIDE I hereby certify that the above statement is a FOR CITY USE ONLY true and complete record of the transactions reported. Organization Name Prepared by Title