Cullman County Privilege Tax - Alabama Department Of Revenue
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2A
D
R
SUBT: CUL
LABAMA
EPARTMENT OF
EVENUE
Revised 11/09
S
, U
& B
T
D
ALES
SE
USINESS
AX
IVISION
M
F
S
Reset
OTOR
UELS
ECTION
Cullman County Privilege Tax
FEIN / SSN __________________________________________________
CN ___________________________________________________
DISTRIBUTOR’S NAME
(FOR OFFICE USE ONLY)
ALABAMA MOTOR FUELS LICENSE NO. _________________________
MONTH OF ____________________________________, _______
ADDRESS
E-MAIL ADDRESS ____________________________________________
TELEPHONE NO. (________)_____________________________
CITY
STATE
ZIP
Check here if new address
Check here for EFT Payment
Check here if Amended Return
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11
13
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Reset Tax Data
GARDEN
SOUTH
OTHER
ARAB
BAILEYTON
COLONY
CULLMAN
DODGE CITY
FAIRVIEW
GOOD HOPE
HANCEVILLE
HOLLY POND
WEST POINT
CITY
VINEMONT
SALES
GASOLINE
1 Taxable Gallons
X
$
0.01
X
$
0.01
X
$
0.01
X
$
0.01
X
$
0.01
X
$
0.01
X
$
0.01
X
$
0.01
X
$
0.01
X
$
0.01
X
$
0.01
X
$
0.01
X
$
0.01
2 Tax Rate
3 Gross Tax
4 Interest
5 Failure to Timely File Penalty
(See instructions on back.)
6 Failure to Timely Pay Penalty
(See instructions on back.)
7 Authorized Credit (Attach letter.)
8 Total Due for Each City
Grand Total Due
9
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the month of activity for which this return is filed for gasoline or any substitutes thereof sold, distributed, or withdrawn from
storage in Cullman County, Alabama.
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
knowledge 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.
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