Form F-5 Annual Survey of State Tax Collections

OMB No. 0607-0585: Approval Expires 03/31/2005
In correspondence pertaining to this report, please refer to the
Census File Number above your address.

F-5

FORM
(4-6-2004)

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

U.S. CENSUS BUREAU

ANNUAL SURVEY
OF STATE
TAX COLLECTIONS
RETURN TO

▼

U.S. Census Bureau
ATTN: Governments Division,
Stop 6800
4700 Silver Hill Road
Washington, DC 20233
Data supplied by
Name

Title

Official address (Number and street,
city, State, ZIP Code)

Area code

Telephone
Number
(Please correct any error in name, address, and ZIP Code)
This form has been approved by the Office of Management and Budget (OMB) and has been given the number
0607-0585. Please note that we have displayed this number in the upper right hand corner of this form. Display of this
number confirms that we have approval from OMB to conduct this survey. If this number were not displayed, we could
not request your participation in this survey.
Please note that this is a national form that applies to governments with wide differences in the size of their service
areas, the amount of the population served, and the extent and complexity of their financial accounts. We estimate
public reporting burden for this collection of information to vary from 1.5 to 10.0 hours per response, with an average
of 3.5 hours per response, including time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding
this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to: Paperwork Project 0607-0585, U.S. Census Bureau, 4700 Silver Hill Road, Stop 1500, Washington, DC
20233-1500. You may e-mail comments to [email protected]; use "Paperwork Project 0607-0585" as the subject.

INSTRUCTIONS
1. Please fill out and return this form as soon as possible.
It can be submitted via fax on 866–803–0407 (toll
free). Please retain a copy for your files.
2. The various taxes imposed by your State are listed in
the column "Tax source," arranged according to the
standard classification applied in Census Bureau
reporting. Any new tax sources, and any items
inadvertently omitted last year, should be added to the
listing.
3. Please enter amounts of all tax revenue of your State
in its most recent fiscal year in the appropriate
column. As a guide, prior-year amounts have been
entered in the adjacent column.

4. If final figures are not available for some items, please
enter estimates and indicate by the letter "E."

5. Report tax amounts in terms of thousands of dollars.

6. Please enter footnotes to indicate changes in tax laws
or administration which materially affected tax yields
within the fiscal year, such as tax repeal, new taxes,
and major changes in rates, bases, exemptions, or
collection timing.

• INCLUDE
a. Taxes of all funds and agencies – Collection aggregates for each tax source comprising amounts
received by all funds and agencies of your State government, net of refunds to taxpayers except as
otherwise indicated.
b. Protested taxes in revenue accounts – Amounts of protested taxes which have been transferred to
revenue accounts because of legal or administrative determination. (See instruction e.)
c. Delinquent taxes – Collections of delinquent taxes and applicable penalties and interest.
d. State collected-locally distributed taxes – Taxes imposed and received by the State government
which are subsequently distributed to local governments.
• EXCLUDE
e. Protested taxes in suspense accounts – Protested taxes paid into suspense funds. (See instruction b.)
f. Locally collected/retained taxes – Locally collected and retained amounts of State imposed taxes.
g. Discounts – Amounts representing discounts or commissions allowed taxpayers.
h. Locally retained tax collection costs – Amounts retained by local government or local officials
representing tax collection costs or fees.
i. Transfers between funds – Amounts representing transfers between funds (except for instruction b) or
any amounts distributed to local governments which were collected in prior fiscal years.
j. Locally imposed supplements – Collections of locally imposed supplements to State taxes, except for
any amounts of such taxes retained by the State to cover administration costs.
If you have any questions concerning this survey, please call the –
Governments Division
Phone: 800–242–4523

USCENSUSBUREAU

Census
tax
code

Tax source

Fiscal year 20 ___
Amount
(in thousands)

FN.
ref.

Fiscal year 20 ___
Amount
(in thousands)

Line

FN. No.
ref.

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FORM F-5 (4-6-2004)