Form 0978 Mississippi – Fill Out and Use This PDF

Quarterly Commercial

Fertilizer Tonnage Report

Firm Name

Permit No.

Instructions

Type or print legibly with ball point pen using

codes. Remit $.25 per ton quarterly on or

Address

Phone

before the 30th of the month following the date

due. If report is not submitted or amount due is

not paid within thirty days after the close of the

quarter, the law requires a penalty of ten

percent of amount due, but in no case less than

City

State

Zip Code

ten dollars ($10.00), must be added to you

check. Show tons in hundredths. See

remittance instructions for further explanation.

Quarter Ending

Date Submitted

Indicate correct container and use.

Description Guaranteed Analysis

Container

Use

N

P2O5

K2O

Tons

(1) Bag

(1) Farm

Destination

UFTRS

Sold

(2) Bulk

(2) Non-Farm

County Code

Code

(3) Liquid

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________

Total Tonnage

I certify that the above statement is true and correct to the best of my

knowledge and belief and represents the tonnage of fertilizer and fertilizer

materials sold by said firm in the State of Mississippi for the quarter ending

$

Fee @ $.25/Ton

______________20_____ on which said firm is due the state a sum of $.25

per ton as inspection fee on each and every ton sold in the state.

$

Penalty 10%

Company Representative (Please Print)

____________________________________________________________

Check #

_

Signature (Sign in Ink)

____________________________________________________________

$

Total Remitted