Form 401C – Fill Out and Use This PDF

Please Check Appropriate Box :

Separate Return

Combined Return

Check box if AMENDED and enter correct Reporting Period

(below) being "amended"

Taxpayer Name	Reporting Period (Quarter)
	[Due 45 days after end of Quarter]
Mailing Address	Business Activity

Check here if mailing address has changed.

RELATED BRANCH INFORMATION: Form 404 must be filed if one of a group of related branches.

Gross Receipts							(Enter Whole Dollars)
1.	Navajo goods
		. . .	. . . . . . . . . . . . . . .	. .	. . . . . . . . . . . . .	. .
2.	Navajo services					+
		. .	. . . . . . . . . . . . . . .	. . .	. . . . . . . . . . . .
3.	Total gross receipts (Add Line 1 and Line 2)					. .=
Deductions
4.	Standard deduction - $125,000		or 10% of Line 3 .			-
				. .	. . . . . . . . . . . .
. . . .5. Salaries, wages, & other compensation paid to Navajos, Form 402						-
6.	Purchases of Navajo goods, Form 403 - Part A					-
7.	Purchases of Navajo services, Form 403 - Part B					-

8.Payments made to the Navajo Nation government, Form 403 - Part C . -

9. Total Deductions (Add Lines 4 through 8) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . = 10. Navajo source gains (Line 3 less Line 9) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . = 11. Business Activity Tax (Line 10 times 5%) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . =

12. Credit for State Taxes Paid on Coal Sales, Form 405 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -

13. Tax paid with extension request (Form 145 must have been timely filed) . . . . . . . . . . . . . . -

14. Interest(s) - if applicable. Calculate interest owed & enter amount (attach calculations) . . . . . +

15. Penalty(s) - if applicable. Calculate penalties owed and enter amount (attach calculations) . . . + 16. TOTAL TAXES DUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . =

ONTC

OFFICE USE

ONLY