Uniform Severance Tax Return - Alabama Department Of Revenue

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A
D
R
SUB: AUST
LABAMA
EPARTMENT OF
EVENUE
06/12
B
& L
T
D
USINESS
ICENSE
AX
IVISION
S
& L
T
S
EVERANCE
ICENSE
AX
ECTION
P.O. Box 327560 • Montgomery, AL 36132-7560 • (334) 353-7827
Uniform Severance Tax Return
Title 40, Chapter 13, Article 3
FOR THE MONTH OF _______________________________, ___________
MONTH OF ACTIVITY
YEAR
Online filing available at:
COMPANY NAME
FEIN/SSN
ACCOUNT NUMBER
ADDRESS
CONTACT PERSON
CITY
STATE
ZIP
TELEPHONE NUMBER
Check here if new address
PRODUCER
PURCHASER
Column A
Column B
Column C
Column D
Column E
Column F
COUNTY
TOTAL TONS
TAX RATE @
COUNTY
MUNICIPALITY
AMOUNT DUE
CODE
SOLD/PURCHASED
10 CENTS PER TON
$0.10
$0.10
$0.10
$0.10
$0.10
$0.10
$0.10
$0.10
$0.10
$0.10
$0.10
$0.10
$0.10
$0.10
$0.10
Taxable Tons (See Schedule, Column I) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Total Tax Due . .
Penalty Due For Failure to Timely File (10% of tax due or $50.00 whichever is greater) . . . . . . . . . . . . . . . . . . .
Penalty Due For Failure to Timely Pay (10% of tax due) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Interest Due (contact the Department of Revenue for rate) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
TOTAL AMOUNT DUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Check here if amount due is remitted via EFT
Under penalties of perjury, I hereby certify this return to be true, complete and accurate.
Signature: ___________________________________________ Title: ______________________________ Date: ________________
Note: This return must be postmarked by the 20th of each month for the previous month. Attach check or money order payable to the
Alabama Department of Revenue for the tax due.
See instructions on the back of this return.

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