County Minnesota tax ID
Contact Phone
Year For quarter ending (check one):
March 31 June 30 September 30 December 31
1 Total county conservation fee collected ........................................... 1
2 Multiply line 1 by 50% (.50). PAY THIS AMOUNT as the state’s share of the fee.......... 2
I declare that this return is correct and complete to the best of my knowledge and belief.
Signature Position Date
Mail check payment and return to Minnesota Revenue, Mail Station 3331, St. Paul, MN 55146-3331
Phone: 651-556-4721 (TTY: Call 711 for Minnesota Relay).
Sign Here Fee
County Conservation Fee Return
You must le this return each quarter to report Minnesota’s share of the fee you collect. Returns are due on or before the
20th day of the month following the end of the quarter.
(Rev. 12/11)
Print or Type
CCF1