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Phone Number Do not write in the space to the right. Rev 6210051 ST-9 W REV 06/12 12 13 Penalty 13 14 Interest I declare that this return (including accompanying schedules and statements) has been examined by me and to the best of my knowledge and belief is true, correct and complete. 11 12 Total State and Local and Prepaid Wireless Fee Due - Add Lines 7(c), 10 and 11(b) City, State, ZIP 9 10 Net State Tax Due - Line 8 minus Line 9 Address Accoun.

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