P.O. Box 5207
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Quarterly Commercial |
Fertilizer Tonnage Report |
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Firm Name |
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Permit No. |
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Instructions |
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Type or print legibly with ball point pen using |
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codes. Remit $.25 per ton quarterly on or |
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Address |
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before the 30th of the month following the date |
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due. If report is not submitted or amount due is |
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not paid within thirty days after the close of the |
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quarter, the law requires a penalty of ten |
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percent of amount due, but in no case less than |
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ten dollars ($10.00), must be added to you |
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check. Show tons in hundredths. See |
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remittance instructions for further explanation. |
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Quarter Ending |
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Date Submitted |
Indicate correct container and use. |
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Description Guaranteed Analysis |
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Container |
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Use |
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P2O5 |
K2O |
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Tons |
(1) Bag |
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(1) Farm |
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Destination |
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UFTRS |
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Sold |
(2) Bulk |
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(2) Non-Farm |
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County Code |
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Code |
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(3) Liquid |
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____________________________________________________________________________________________________________________ |
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____________________________________________________________________________________________________________________ |
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____________________________________________________________________________________________________________________ |
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____________________________________________________________________________________________________________________ |
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____________________________________________________________________________________________________________________ |
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____________________________________________________________________________________________________________________ |
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____________________________________________________________________________________________________________________ |
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____________________________________________________________________________________________________________________ |
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____________________________________________________________________________________________________________________ |
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____________________________________________________________________________________________________________________ |
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___________________________________________________________________________________________________________________ |
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Total Tonnage |
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I certify that the above statement is true and correct to the best of my |
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knowledge and belief and represents the tonnage of fertilizer and fertilizer |
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materials sold by said firm in the State of Mississippi for the quarter ending |
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Fee @ $.25/Ton |
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______________20_____ on which said firm is due the state a sum of $.25 |
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per ton as inspection fee on each and every ton sold in the state. |
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$ |
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Penalty 10% |
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Company Representative (Please Print) |
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____________________________________________________________ |
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Check # |
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_ |
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Signature (Sign in Ink) |
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____________________________________________________________ |
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$ |
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Total Remitted |
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