Motor Fuel Tax Return Form - Town Of Fyffe Gasoline

Town of Fyffe Gasoline/Motor Fuel Tax Return

Filing Period: Month ___________________ Year 20__________

FEIN or SSN# _________________________________

RDS Account #:

Discount or

Jurisdiction

Tax

Rate

Penalty

Fuel Type

Location

Code

Type

Code

# of Taxable Gallons

Tax Rate

Net Tax Due

In City

20% Penalty if

Gasoline

9441

50

91

3¢

Late No Discount

Limits

In Police

20% Penalty if

Gasoline

9441

50

92

1 1/2¢

Jurisdiction

Late No Discount

20% Penalty if

Diesel Fuel

In City Limits

9441

50

93

2¢

Late No Discount

In Police

20% Penalty if

Diesel Fuel

9441

50

94

1¢

Jurisdiction

Late No Discount

Total Tax Due $________________________

* Sign Your Return - I declare under penalties of perjury that the above information (and any accompanying schedules) are to the best of my knowledge

and belief, a true and accurate statement for the period indicated.

Signed __________________________________________________Date_____________________ Telephone #______________________________

FORM DISCLAIMER:

Please note that the administration and rate changes on the RDS Advisory and RDS tax forms are updated once the required information has been received, verified, and validated in compliance with RDS policy. Any information received before or after the

publication of an RDS Advisory or tax form will not be guaranteed to appear on said forms until all such requirements have been met. RDS is not responsible for incorrect information and/or improper use of the information provided. All updates are completed on a timely basis once

the requirements have been met. For the most current RDS administration and/or rate information provided, please visit our website at RETURNED CHECK DISCLAIMER: When you make a payment by check, you authorize us to use information from your check

to make a one-time electronic fund transfer from your checking account according to the terms of your check or to process that transaction as a check. When we use your check to make an electronic fund transfer, funds may be withdrawn from your checking account as soon as the

same day we receive your payment, and you will not receive your check back from your financial institution. If there are insufficient funds in your checking account, you authorize us to charge a Returned Payment Fee in the amount set forth below and collect that amount through an

electronic fund transfer from your checking account, if permitted by applicable law. IF YOUR CHECK OR OTHER PAYMENT IS RETURNED UNPAID by your bank, we may, if permitted by applicable law, charge a Returned Payment Fee of $ 50 in KY and VA; $40 in DE and MS; $

35 in MD; $30 in AL, OH, SC, TN, and TX; $25 in AR, IL, MO, NC and WV; $20 in IN; the greater of 5% of the check or (i) $30 in GA or (ii) $25 in LA; the greater of 5% of the check or (i) $25 if the check is under $50, (ii) $30 if the check is between $50 and $300 or (iii) $40 if the

check is over $300 in FL. Effective July 1, 2010, each returned item received by RDS due to insufficient funds will be electronically represented to the presenters’ bank no more than two times in an effort to obtain payment. RDS is not responsible for any additional bank fees that will

accrue due to the resubmission of the returned item.

Remittance Address:

Tax Division  PO Box 830725  Birmingham, AL 35283-0725  (800) 556-7274  Email:  Website:

Town of Fyffe Gasoline/Motor Fuel Tax Form

June 2010