Form R-5289 - Dealer'S Motor Fuels Tax And Inspection Fee Report Page 3

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Louisiana Department of Revenue
R-5291 (7/04)
Motor Fuel Tax Multiple Schedule of Receipts
Company name __________________________ Account number ________________ Schedule number ____________ Month of ______________________
Type of schedule
PC – Type of product*
E –
Jet Fuel
1
Gallons received tax paid
A –
Gasoline
F –
Diesel
2
Gallons received inspection fee paid
B –
Alcohol
G –
Kerosene
3
Gallons received tax and inspection fee paid
C –
Gasohol
H –
Other
4
Gallons imported from another state
D –
Aviation gasoline
5
Gallons manufactured
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
Point of
Document
Name of carrier
Origin
Destination
Acquired from
Date
number
Gallons
Other
Total
*Note: Use a separate schedule for each product.

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Parent category: Financial
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