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4 North Dakota Office of State Tax Commissioner
2021
5 Telecommunications Gross Receipts Tax 5
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7 7
8 (A) X Check this box if this is an amended return. (F) X Check this box if you are no 8
9 longer in business and enter your 9
10 last day of business. 10
11 Account FEIN99999 Due 05/01/2021 11
12 Number Date MM/DD/YYYY 12
13 (C) X Check this box if this business has 13
Period
14 12/31/2021 changed ownership. Provide 14
15 Ending name, address, and telephone 15
16 number of new owner: 16
17 17
Taxpayer NameXXXXXXXXXXXXXXXXX NameXXXXXXXXXXXXXXXXXX
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Address1XXXXXXXXXXXXXXXXXXXXXX AddressXXXXXXXXXXXXXXX
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Address2XXXXXXXXXXXXXXXXXXXXXX City,State,ZipXXXXXXXX
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City,State,ZipXXXXXXXXXXXXXXXX (999) 999-9999
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24 Calendar Year 2020 Telecommunications Carrier Gross Receipts From Retail Sales 24
25 (North Dakota Century Code ch. 57-34) 25
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1. Telecommunications service originated AND terminated in North Dakota and billed to a
27 North Dakota station (include essential and nonessential service) 999999999999999 27
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2. Interstate and international service originated OR terminated in North Dakota and billed to a
29 North Dakota station (include essential and nonessential service) 999999999999999 29
30 30
3. Cellular and other mobile services provided by the home service provider of a customer
31 whose place of primary use is in North Dakota 999999999999999 31
32 4. Gross receipts from pay telephones located in North Dakota 999999999999999 32
33 5. Telegraph service billed to a North Dakota station 999999999999999 33
34 6. Amounts assessed against members for the operation and maintenance of the business 999999999999999 34
35 7. Recovered telecommunications service charges previously written off as uncollectible 999999999999999 35
36 36
8. Charges to another telecommunications carrier for directory assistance originated by
37 a caller in this state 999999999999999 37
38 9. Total Taxable Gross Receipts (sum of lines 1-8) 999999999999999 38
39 39
40 40
41 Deductions 41
42 10. State and local sales and use taxes and federal excise taxes if included on line 9 999999999999999 42
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11. Amounts paid to another telecommunications carrier for directory assistance
44 originated by a caller in this state 999999999999999 44
45 12. Telecommunications service charges written off as uncollectible if included on line 9 999999999999999 45
46 46
13. North Dakota telecommunications gross receipts taxes paid by the subscriber
47 if included on line 9 999999999999999 47
48 14. Amounts collected to preserve and advance universal service if included on line 9 999999999999999 48
49 15. Total Deductions (sum of lines 10-14) 999999999999999 49
50 16. Adjusted Gross Receipts (line 9 less line 15) 999999999999999 50
51 .025 51
17. Tax rate (2.5 percent)
52 18. TAX ON AMOUNT ON LINE 16 (line 16 multiplied by line 17) 999999999999999 52
53 53
54 The tax due on line 18 should not be remitted with this form. 54
55 I declare under the penalties of N.D.C.C. § 12.1-11-02, which provides for a Class A misdemeanor for making a false statement in a governmental 55
56 matter, that this return, including any accompanying schedules and statements, has been examined by me and to the best of my knowledge and belief 56
57 is a true, correct, and complete return. 57
58 Taxpayer Signature Date Title 58
59 59
60 Contact person (please print or type) Contact telephone number 60
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22008 Mail to: Office of State Tax Commissioner,
PO BOX 5623, Bismarck ND 58506-5623 NACTP
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