Monthly Report Form Of Sale Of Motor Fuel - 2009

MONTHLY REPORT OF SALE OF MOTOR FUEL

Business License

City of Joliet

Name of Station

____________________________________

150 West Jefferson Street

Joliet, Illinois 60432

State Tax Number

____________________________________

Telephone: (815) 724-3905

Fax:

(815) 740-1221

Address

____________________________________

____________________________________

Telephone Number

____________________________________ Month _________________________ Year _____________

As provided by Ordinance No. 7649 of the Municipal Code of the City of Joliet, Illinois.

MY NAME IS (PRINT): ____________________________________

MAKE CHECK PAYABLE TO: CITY COLLECTOR

ADDRESS: _____________________________________________

MAIL TO:

CITY COLLECTOR

CITY OF JOLIET

CITY: _____________________ STATE: ___________________

150 WEST JEFFERSON STREET

JOLIET, ILLINOIS 60432

ZIP CODE: _________________

E-MAIL ADDRESS: ______________________________________

TO PAY BY VISA OR MASTERCARD, FILL OUT THE PORTION BELOW AND SIGN YOUR NAME:

MASTERCARD

VISA

NUMBER: ____ _____ ____ ____

____ _____ ____ ____

____ _____ ____ ____

____ _____ ____ ____

EXPIRATION DATE __________/__________

SIGNATURE: ___________________________________________

1. TOTAL NUMBER OF GALLONS SOLD (As Indicated on Illinois Retailers Occupation Tax Form Line 2 (7) of Form-Check Proper Form)

_____ ST-1-A

_____ ST-2

_____ ST-1-B

_____________________________GALLONS

2. AT TAX RATE OF $0.01 PER GALLON

$_____________________________

3. PENALTY OF 2% PER MONTH IF FILED LATE

$_____________________________

(SEE NOTE BELOW)

4. TAX AMOUNT REMITTED

$_____________________________

UNDER PENALTIES AS PROVIDED BY LAW, THE UNDERSIGNED AND ACCOMPANYING SCHEDULE IS TRUE AND ACCURATE TO THE BEST OF

HIS/HER KNOWLEDGE AND BELIEF AND IS TAKEN FROM THE BOOKS AND RECORDS OF THE BUSINESS FOR WHICH THIS IS FILED.

SIGNATURE OF TAXPAYER _________________________________________________________________________________

SIGNATURE OF PERSON PREPARING RETURN ________________________________________________________________

DATE __________________________________TELEPHONE NUMBER ______________________

Attention: gallon measurement is required in completing this form. If your records are in liter measurement, multiply the total by the official factor of .2641721 to convert to U.S.

gallons.

Please return report and remittance to the Business License Division, City of Joliet, by the last day of the following month. If the return is filed late, a penalty of 2% per month is

assessed. This penalty must be shown on line 3 and accompany the tax remittance.

Please check here if address, phone number, or e-mail

changes are indicated above.

Revised 06/2009