Schedule B Motor Fuel Tax Multiple Schedule Of Disbursements Form - Louisiana Department Of Revenue

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R-5290 (7/06)
Page _____ of _____
Schedule B
Motor Fuel Tax Multiple Schedule of Disbursements
Company Name
LA Revenue Account Number
Type of Schedule
Product Type
Filing Period
Mode of Transport
Product Type (Only one product type per page)
Type of Schedule
B = Barge
065 – Gasoline
130 – Jet Fuel
228 – Dyed Diesel
6
Gallons sold to US government
7
Gallons sold to licensees with tax and/or fee; including own use
J = Truck
123 – Alcohol
072 – Dyed Kerosene
170 – Clear Biodiesel
8
Gallons sold to unlicensed customers with tax and/or fee
R = Rail
124 – Gasohol
142 – Clear Kerosene
171 – Dyed Biodiesel
S = Ship
125 – Aviation Gasoline160 – Clear Diesel
Other ________________
9
Gallons exported – destination state tax paid
PL = Pipeline
10 Gallons of aviation fuels exported by licensed Aviation Fuel Dealer
11 Gallons of dyed diesel fuels sold for use in seagoing vessels
ST = Stationary Transfer
12 Gallons of aviation/dyed diesel fuels sold for non-taxable purposes
BA = Book Adjustment
13 Gallons of aviation/dyed diesel fuels sold for taxable purposes
(6)
(7)
(1)
(2)
(3)
(4)
(5)
Purchaser
City, State of
Doc.
Net
Date
Name
Rev. ID
Mode
Carrier Name
Origin
Destination
Number
Gallons
Total

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