Form Cmft-2-X - Amended Multiple-Site Form - 2010
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Illinois Department of Revenue
CMFT-2-X
Amended Multiple-Site Form
Rev
01
Attach to Form CMFT-1-X.
Form
027
Do not write above this line.
Business name: ___________________________________
Account ID:
____ ____ ____ ____ - ____ ____ ____ ____
Reporting period you are amending:
__ __/__ __/__ __ __ __ through __ __/__ __/__ __ __ __
Month
Day
Year
Month
Day
Year
Column A
Column B
You must round your fi gures to whole dollars. See instructions.
Number of taxable gallons
Amount of Tax
Site where taxable retail sales were made:
Location code
_____________________________________
4 _______________ X
$.04
=
5 ________________
Site name
_____________________________________
Site address
_____________________________________
_____________________________________
City, state, ZIP
_____________________________________
Location code
_____________________________________
4 _______________ X
$.04
=
5 ________________
Site name
_____________________________________
Site address
_____________________________________
_____________________________________
City, state, ZIP
_____________________________________
Location code
_____________________________________
4 _______________ X
$.04
=
5 ________________
Site name
_____________________________________
Site address
_____________________________________
_____________________________________
City, state, ZIP
_____________________________________
Location code
_____________________________________
4 _______________ X
$.04
=
5 ________________
Site name
_____________________________________
Site address
_____________________________________
_____________________________________
City, state, ZIP
_____________________________________
Location code
_____________________________________
4 _______________ X
$.04
=
5 ________________
Site name
_____________________________________
Site address
_____________________________________
_____________________________________
City, state, ZIP
_____________________________________
Location code
_____________________________________
4 _______________ X
$.04
=
5 ________________
Site name
_____________________________________
Site address
_____________________________________
_____________________________________
City, state, ZIP
_____________________________________
This form is authorized by the County Motor Fuel Tax Law. Disclosure of this information is REQUIRED. Failure to provide
information could result in a penalty. This form has been approved by the Forms Management Center.
IL-492-2462
*002711110*
CMFT-2-X front (R-1/10)
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