Form Sev 501 - Severance Tax On All Coal Products Return - 2000 Page 2

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Jackson
Johnson City
Knoxville
Memphis
Nashville
Chattanooga
Check appropriate box
and fill in number below:
FEIN or SSN
Under the penalties of perjury, I declare that I have examined this report, and to the best
of my knowledge, it is true, correct and complete.
SIGN
HERE
Taxpayer Signature
Date
SIGN
HERE
Preparer other than taxpayer
Date
Tax Preparer's Address

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