CITY OF GLEN DALE, WEST VIRGINIA

402 WHEELING AVENUE  GLEN DALE, WEST VIRGINIA 26038 

PHONE 304-845-5511

QUARTERLY RETURN BUSINESS AND OCCUPATIONAL TAX

RETURN AND REMITTANCE OF THE AMOUNT OF TAX NO LATER THAN 30 DAYS AFTER THE END OF THE QUARTERLY PERIOD

NAME                                                      

ADDRESS                                                     

STATE TAX ACCOUNT NUMBER                                   

For the Quarter Ending                                     

TOTAL ALL CLASSES                                

PENALTIES*                                     

TOTAL AMOUNT DUE                                

Penalties - 5% for the first month delinquency plus 1% for each succeeding month

I hereby certify that the above is true and correct

Given under my hand this day                                  

Signed                                                       

By                                                          

Official Title