Form Mf-52b - Motor Fuel Tax Multiple Schedule Of Disbursements Special Fuel - 2004

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KANSAS DEPARTMENT OF REVENUE
CUSTOMER RELATIONS
915 SW HARRISON ST.
TOPEKA, KANSAS 66625-8000
Phone Number: (785) 368-8222
Fax: (785) 296-4993
MOTOR FUEL TAX MULTIPLE SCHEDULE OF DISBURSEMENTS SPECIAL FUEL
COMPANY NAME
LICENSE NO.
FEIN NO.
TYPE OF SCHEDULE
MONTH & YEAR
Type of Schedule
5 - Gallons delivered tax collected
8 - Gallons delivered to US Government tax exempt
PC - Product Code
6 - Gallons delivered to licensed motor fuel distributors tax not collected 9 - Gallons delivered to other tax exempt entities
(See Reverse)
7 - Gallons exported to the state of __________________
10 - Gallons delivered to Consumers in Tank Car, Transport, or Pipeline Lots
(12)
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
POINT OF
NAME OF
CARRIER
ORIGIN
DESTINATION
TERMINAL
SOLD
PURCHASER’S
MANIFEST
GROSS
NET
PC
CARRIER
FEIN
MODE
CITY, STATE
CITY, STATE
CODE
TO
FEIN
DATE
NUMBER
GALS
GALS
TOTAL
MF-52B (Special Fuel)
SEE INSTRUCTIONS ON REVERSE
(Rev. 4/04)

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