Form B&l: Jcmt-1 - Jackson County Coal Severance Tax Report

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B&L: JCMT-1

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LABAMA

EPARTMENT OF

EVENUE

B

& L

T

D

USINESS

ICENSE

AX

IVISION

Acct. No. _____________________

P.O. Box 327560 • Montgomery, AL 36132-7560 • (334) 353-7827

Control No. ___________________

Jackson County

PRODUCTION PERIOD

MONTH / YEAR

Coal Severance Tax Report

TAXPAYER NAME

FEIN

ADDRESS

CITY

STATE

ZIP

CONTACT PERSON (PLEASE TYPE OR PRINT)

TELEPHONE

(

)

TAX DUE

MINE NAME

PERMIT NUMBER

TONS PRODUCED

@ 20 CENTS PER TON

$

Total Tons and Tax Due at 20 Cents Per Ton . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$

Penalty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$

Interest at the current prevailing rate from Date of Delinquency. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$

Total Amount Due And Payable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

The undersigned officer testifies and says on oath that he is ___________________________________________________ of

TITLE

__________________________________________________ and that as such officer he has supervision over the books and

accounts of said operations and controls the manner in which such books are kept; that he knows that such books have been

kept in good faith during the period covered by the foregoing report and to the best of his knowledge and belief, the information

given in said report is in exact accordance therewith; and that said report is a correct statement of the tons of coal taken from

all pits as shown above.

Name _____________________________________________________

(PLEASE PRINT)

Signature _____________________________________________________

NOTE: This report is due by the 20th of each month covering the operations for the previous month. Attach to report

check or money order payable to Alabama Department of Revenue.

Returns must be submitted electronically at