Form Mfd 1-S/af - Distributor Report Motor Fuel And Aviation - Departament Of Safety Road Toll Bureau, State Of New Hampshire
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1
2STATE OF NEW HAMPSHIRE
FOR OFFICIAL USE ONLY
OFFICE AUDIT:
DEPARTMENT OF SAFETY
By: __________ Date:___________
ROAD TOLL BUREAU
33 HAZEN DRIVE, CONCORD, NH 03305
VERIFICATION
TELEPHONE: (603) 271-2311
By:__________ Date:___________
TDD Access: Relay NH 1-800-735-2964
DISTRIBUTOR REPORT
MOTOR FUEL AND AVIATION
MONTH OF:______________ YEAR:________
NAME:______________________________________________
th
Report must be postmarked no later than the 20
day of the
month following the reporting period.
ADDRESS:___________________________________________
Telephone Number:______________________________
CITY/TOWN:_________________________________________
License Number: _________________________________
STATE:________________________ ZIP:__________________
FEIN: ____________________
UNDYED
AUTOMOTIVE
AVIATION
INVENTORIES AND RECEIPTS
SPECIAL
JET FUEL
GASOLINE
GASOLINE
FUEL
1. Opening Inventory (Include Items In Transit)
2. Receipts At Locations In NH From Outside NH
(Sch. 2)
3. Receipts At Locations In NH From NH
(Sch. 3)
4. Direct Shipments To Other States
(Sch. 4)
5. Direct Shipments To Customers In NH
(Sch, 5)
6. Inventory Transfers And Adjustments
(Sch. 6)
7. Total Charges
8. Closing Inventory (Include Items In Transit)
9. Total Gallons To Be Accounted For (Line 7 Minus Line 8)
JET FUEL
UNDYED
AUTOMOTIVE
AVIATION
SPECIAL
DISTRIBUTION
F.A.R. PART 121
Private and
GASOLINE
GASOLINE
FUEL
AIR CARRIERS
Commercial
10. Sales Out Of NH
(Sch. 10)
11. Sales To NH Licensed Distributors
(Sch. 11)
12. Sales To US Gov’t and It’s Agencies (Bulk)
(Sch 12)
13. Sales To Local and State Gov’t or It’s Agencies (Bulk)
(Sch 13)
14. Gain Or Loss (Indicate Gain as “G” and Deduct)
15. Total Non-Taxable Distribution (Lines 10 through 14)
16. Taxable Sales In NH
(Sch 16)
17. Taxable Use (Personal)
(Sch 17)
18. Total Taxable Distribution (Line 16 + Line 17)
19. Total Gallons To Be Accounted For (Line 19 =Line 9)
TAX COMPUTATION
20. Taxable Distribution (Line 18)
Less: Retail Dealer Sales To:
21. US Gov't and it's Agencies
(Sch. 21)
22. Local/State Gov't or it's Agencies
(Sch. 22)
23. Adjustments To Prior Reporting Period(s) Adjustments
24. Results Of Lines 21 Through 23
25. Net Taxable Gallons (Line 20 +/- Line 24)
26. TAX RATE PER GALLON
$0.18
$0.005
$0.18
$0.04
$0.02
27. TAX DUE BY PRODUCT (LINE 25 XLINE 26)
NET DUE (TOTAL OF LINE 27)
$
Name:___________________________________________
Signature: ___________________________________________________
(Please Print)
Title:_____________________________________________
Date:_______________________________________________
(Signed under penalty of unsworn falsification pursuant to RSA 641:3)
MAKE CHECKS PAYABLE TO: STATE OF N.H.-ROAD TOLL BUREAU
MFD 1-S/AF (Revised 07/05)
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