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2. 
4. Monthly Report of Sale of Motor Fuel
   Village Code, Section 37.57 provides for the imposition of a tax upon the privilege of purchasing diesel fuel at retail in the Village at the rate of $0.11 per gallon and all other motor fuels at the rate of $0.04 per gallon. Section 37.58 requires every dealer to secure the tax from each purchaser and pay over to the Village.
6. Due by the 20th of the month following the reporting month.
10. Reporting Month/Year*
12. Name of Station/Business*
13. State I.D. Number*
15. Address*
    City, State, Zip
17. Telephone Number*
19. 1A. Total number of gallons sold (as indicated on the Illinois Retailer Occupation Tax Form ST-1, total line 7, A, C, E, G, I).*
    GASOLINE
21. 1B. Total number of gallons sold (as indicated on the Illinois Retailer Occupation Tax Form ST-1, total line 7, A, C, E, G, I).*
    DIESEL
23. 2. Gasoline tax rate of $0.04 per gallon*
25. 3. Diesel tax rate of $0.11 per gallon*
27. 4. Penalty of 2% per month if filed late**
29. 5. Total tax amount remitted (Items 2+3+4)*
31. *Village Code, Section 37.62 states that if for any reason any tax is not paid when due, the dealer shall pay a penalty at the rate of two (2) percent per month on the amount of tax which remains due but unpaid. This penalty must be shown on Line 4 and accompany the tax remittance.
33. ATTENTION: Gallon measurement is required in completing this form. If your records are in liter measurement, multiply the total by the official factor of 0.2641721 to convert to U.S. gallons.
37. Under penalties as provided by the law the undersigned and accompanying schedule is true and accurate to the best of his/her knowledge and belief and is taken from the books and records of the business for which this is filed.
39. Make checks payable to: VILLAGE OF CHANNAHON Mail report and checks to: Finance Department 24555 S. Navajo Drive Channahon, IL 60410
41. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
43. Signature of Taxpayer*
44. Date*
    Date
45. Phone*
47. Signature of Person Preparing Report*
48. Date*
    Date
49. Phone*
51. 
Leave This Blank:


53. 1. Receive an email copy of this form.
54. Email address

    This field is not part of the form submission.

55. Submit

* indicates a required field