Shelby County Business Revenue 

               Sales, Use, Rental, Lodging & Tobacco Tax Return
                                                                                       Mail this return with remittance to:
Reporting Period             _______________                                            Shelby County Business Revenue Office
                                                                                        200 West College Street, Room 115
Shelby County Account #      _______________                                                           Columbiana, AL 35051
                                                                                 Phone: 205-670-6520   Email: salestax@shelbyal.com
Business Name & Address:
                                                                                            Make check payable to:
                                                                                        Shelby County Business Revenue

                                                                                        Enter Amount                   Enter Check #
      Check here if your business is closed                                       $

                                                 (A)                  (B)               (C)                     (D)                 (E)
          Type of Tax                           Gross Taxable         Total       Net Taxable Sales           Tax Rate              Gross Tax Due  
                                                 Sales               Deductions*  (Column A-Column B)                  (Column C x Column D) 
SALES (General)                                                                                                 .01

SALES (Machine Rate/Vending)                                                                                   .00375

SALES (Automotive)                                                                                             .00375

USE-Sellers /Consumer (General)                                                                                 .01

USE-Sellers /Consumer (Auto/ Machine Rate)                                                                     .00375

RENTAL (General)                                                                                                .03

RENTAL (Automotive)                                                                                            .01125

LODGING                                                                                                         .07

TOBACCO                                                                                                         .04
(No. of Unstamped Tobacco Products Sold  x 0.04)
By signing this report I am certifying that this report, including   (1) Total Tax Due (Total of Column E)
any accompanying schedules or statements, is to the best of 
my knowledge and belief, a true and complete report for the          (2) Failure to Pay Timely Penalty 10%
period stated. 
                                                                                 (Line 1 x .10)
                                                                     (3) Failure to Timely File Penalty 10%
                                                                                 (Line 1 x .10)
Signature                       Title   
                                                                     (4) Interest (Line 1 x .0049 per month delinquent)

Email (required)                                                     (5) Discount for Timely Payment of
                                                                      Sales and Lodging Tax
                                                                      (5% on $100 or less, 2% on over $100, 
                                                                            Maximum Discount of $400) 
Date                            Telephone                             No Discount on Use, Rental or Tobacco Tax 

PLEASE NOTE:                                                         (6) Net Tax Due (Lines 1-5)              or
In accordance    with Code Section   40-23-7,    returns              Delinquent Taxes (Lines 1+2+3+4)
and  remittances  are  due  and  payable  in     monthly 
installments  on or  before  the  20th  day  of  the  month          (7) For Automobile Dealers: Add # of
next  succeeding  the  month  in  which  the  tax  accrues.  If  the  vehicles withdrawn at $1.25 each
20th  falls  on  a  weekend  or  holiday,  the  return  must  be 
submitted  on  or  before  the  next  working  day  to  be  timely   (8) Credit (Attach Documentation)
filed.
                                                                      Total Amount Due & Enclosed
Per  Code  Section  41-1-21,  failure  to  make  payment  in  a 
timely  manner,  or  failure  to  provide  such  evidence  of        *Allowable deductions include wholesale sales, auto and
payment  in  a  timely  manner,  shall  subject  the  affected       machine trade-ins, labor and service, deliveries outside
taxpayer  to  penalty, interest, and loss of applicable discount.    jurisdiction, governmental agencies, gas or lube oils, etc.