Form 81-015a - Schedule Of Disbursements Supplier, Restrictive Supplier, Importer And Blender Page 2
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3Iowa Department of Revenue
Schedule of Disbursements
Supplier, Restrictive Supplier, Importer and Blender
81-015a (7/18/06)
Company Name
License Number FEIN:
Schedule Code:
Product Code:
Month/Year
Schedule Code:
Product Code (list in box above) Only one product per schedule.
6X Gallons delivered to suppliers or permissive
065 Gasoline
130 Jet Fuel
5
Gallons delivered tax collected.
079 E85
142 Kerosene - undyed
5x Gallons delivered and partially taxed.
suppliers on exchange agreements.
123 Alcohol
161 Low Sulfur Diesel #1-undyed
6
Gallons delivered to motor fuel
7
Gallons exported.
124 Gasohol
167 Low Sulfur Diesel # 2 - undyed
10E Gallons delivered to customers representing
licensee - tax not collected.
125 Aviation Gasoline
284 Bio-diesel undyed (B-100)
6B Gallons sold tax-exempt, customer
uncollectible motor fuel taxes.
226 High Sulfur Diesel Fuel - dye added
285 Soy Oil
227 Low Sulfur Diesel Fuel - dye added
___Other (see FTA Product Code List)
is a licensed blender.
11A Diversion to state of: ________________
11B Diversion from state of: ______________
6F Gallons sold for tax-exempt
purposes from in-state terminals.
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
Point Of
Purchaser
Purchaser
Purchase
Bills Of
Carrier Name
Carrier FEIN Mode
Origin
Dest.
Name
FEIN
Date
Lading
Gross Gallons
Totals:
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