CITY OF DEMOPOLIS
Statement
Gasoline Motor Fuel Distributor
From: To:
Distributor Name: City of Demopolis
Distributor Address: PO Box 580, Demopolis AL 36732
Distributor Email: sam.gross@demopolisal.gov
Distributor Phone:
month of:
Vendor Gallons
Rate per
Gallon
Total
Subtotal from other pages:
Total:
Vendor Gallons
Rate per
Gallon
Total
Subtotal from other pages:
Total:
Signed by:
Title:
Date:
0.01
Return this form and payment to: City of Demopolis, PO Box 580, Demopolis, Al 36732
Gasoline and Diesel delivered/sold in the City Limits or Police Jurisdiction of the City of Demopolis for the:
City Limits: (attach list if space not available, but include totals on this sheet)
Police Jurisdiction: (attach list if space not available, but include totals on this sheet)
in year:
Total Amount Submitted:
I do hereby certify that the amount of tax due on gallons of gasoline and diesel sold in the City of Demopolis
and/or its Police Jurisdiction is correct to the best of my knowldege:
Payments are due on or before the 10th of each month.
0.02
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