Fuel Delivery Form - Navajo Tax Commission
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1F
D
F
UEL
ELIVERY
ORM
Note: Fuel deliveries must be reported within 48 hours of delivery by filing this form with the Office of
the Navajo Tax Commission, Post Office Box 1903, Window Rock, Arizona 86515. One form should be
filed for each load of fuel delivered within the Navajo Nation. Fax Number (928) 871-7608.
Company Name
License Number
Mailing Address
Bill of Lading No.:
Navajo Nation Manifest No.:
Where Picked Up:
Date Delivered:
Recipient/Retailer Facility
Location
Type of Fuel
Total Net Gallons
I declare that the information contained in this document and any attachments thereto is true and correct to
the best of my knowledge and belief pursuant to all Navajo Nation laws and regulations.
x
(
)
/
/
Taxpayer or Duly Authorized Agent Signature
Print or Type Name
Telephone Number
Date
ONTC
FET Fuel Delivery Form
Revised: 5/6/2002
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