A
D
R
SUBT: MFCO
LABAMA
EPARTMENT OF
EVENUE
Reset
Revised
10/11
B
L
T
D
USINESS AND
ICENSE
AX
IVISION
M
F
S
OTOR
UELS
ECTION
Monthly Tax Return of State Administered County Taxes on Gasoline and Motor Fuels
DISTRIBUTOR’S NAME
(FOR OFFICE
FEIN / SSN __________________________________________________
CN
___________________________________________
USE ONLY)
ADDRESS
ALABAMA MOTOR FUELS LICENSE NO. _________________________
MONTH OF____________________________________, _______
CITY
STATE
ZIP
E-MAIL ADDRESS ____________________________________________
TELEPHONE NO. (________)_____________________________
Check here if new address
Check here for EFT Payment
Check here if Amended Return
Column 1
Column 2
Column 3
Column 4
Column 5
Column 6
Column 7
Column 8
Column 9
Column 10
COUNTY
TAXABLE
TAXABLE
TOTAL
RATE
GROSS
INTEREST
PENALTY
AUTHORIZED
TOTAL DUE
GASOLINE
MOTOR FUELS
TAXABLE GALLONS
PER
TAX DUE
(Instructions on back)
CREDIT
(Cols. 6 + 7 + 8 – Col. 9)
GALLONS
GALLONS
(Col. 2 + Col. 3)
GALLON
(Col. 4 X Col. 5)
(Attach credit letter)
BULLOCK
$.03
LOWNDES
$.02
REMITTANCE DUE (one check for all amounts due)
This return and any remittance due must reach the Alabama Department of Revenue no later than the 20th day of the month next succeeding the month of activity for which this return is filed for gasoline or any substitutes thereof and motor fuel sold,
distributed, or withdrawn from storage in the above counties.
AFFIDAVIT MUST BE EXECUTED
Make check payable to: Alabama Department of Revenue
(Form MFT-V must be submitted with payment, unless payment is made electronically.)
UNDER PENALTIES OF PERJURY, I declare that I have examined this return and accompanying schedules and statements and, to the best of my knowl-
edge and belief, they are true, correct, and complete.
Mail to: Alabama Department of Revenue
Motor Fuels Section
P.O. Box 327540
Affiant Signature _______________________________________________________ Title ____________________________ Date ________________
Montgomery, AL 36132-7540
Subscribed and sworn to before me on this the ________ day of ______________________, ___________
Telephone Number: (334) 242-9608
Fax Number: (334) 242-1199
Signature of Notary Public ____________________________________________________ My commission expires _________________, ___________
Web site:
A monthly return must be filed on or before the 20th of each month following the month of activity.