Town of Independence, Virginia
Meals Tax
Filing Form
For Month __________________ Year _______________
1. Gross Food Sales for the Month $__________
2. 5% of Gross Food Sales $__________
3. Amount Retained by Food Sales Agent for Collection Fee:
Line 2 multiplied by 5% $___________
4. Amount To Be Remitted (Line two minus line three) $___________
Firm Remitting Tax: _____________________________
*Date Remitted: ____________ Signed: _______________________________________
*Tax must be remitted by 20th of each month following collection, in order to retain 5% collection fee.