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2. Business Name
4. Business Address
5. City
7. State
8. Zip Code
12. Reporting Period

    Per State rules, bag fee reporting and payment is quarterly. 

14. Quarter Beginning
    Quarter Beginning
15. Quarter Ended
    Quarter Ended
17. Payment Instructions

    By the 20th of the month following the Quarter Ended date above, please print and send this form and payment to the address listed below: 

    City of Wheat Ridge
    Attn: Finance Division/Bag Fee
    7500 W. 29th Ave., Wheat Ridge, CO 80033

19. How to Calculate Total Due

    To calculate the total due multiply the total number of disposable bags that you sold/distributed by the 10-cent bag fee. Then, multiply the result by 60%. 

    You only owe the City 60% of what you collect. You keep 40%. 

    For example, if your business distributed 100 bags you would multiply 100 by .10 cents which equals 10 dollars.  Then, you would send $6.00 payable to the City of Wheat Ridge.

21. Total Number of Disposable Bags Distributed*
22. Total Due and Payable*
26. I HEREBY CERTIFY UNDER PENALTY OF PERJURY THAT THE STATEMENTS MADE HEREIN ARE TO THE BEST OF MY KNOWLEDGE, TRUE AND CORRECT.
28. Acknowledgement*

    1. I have read and understand the above statement
30. Name*

    Please enter your first and last name

31. Title*

    Please enter your title/relation to the business

33. Email Address*

    Please enter a valid email address

34. Phone Number*

    Please enter a valid phone number

Leave This Blank:


40. 1. Receive an email copy of this form.
41. Email address

    This field is not part of the form submission.

42. Submit Submit and Print

* indicates a required field