Liquefied Petroleum Gas (Lpg) User Tax Return Form
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1
2Name:
License Number:
Address:
Return Period:
Return Due Date:
Liquefied Petroleum Gas (LPG) User Tax Return
Mail
Remittance Center
Return to:
PO BOX 5055
Check here if this is an amended return
Sioux Falls, SD 57117-5055
Check here if final return and license to be cancelled
When applicable, report in whole gross gallons only.
Column A
Column B
Column C
Column D
Vehicle #1
Vehicle #2
Vehicle #3
Vehicle #4
Vehicle Information
1
1
Odometer reading from last day of prior reporting period
2
2
Odometer reading from last day of current reporting period
3
3
Miles driven during current reporting period
Subtract Line 1 from Line 2
4
4
Miles driven off of roads and highways
5
5
Highway use miles --- Subtract Line 4 from Line 3
6
6
Vehicle’s Average Miles Per Gallon (MPG) – Determine
from your records
7
7
Gallons consumed during period – Divide Line 5 by Line 6
8
Tax-paid gallons of LPG purchased during the current
8
reporting period – (Your records must contain copies of sales
tickets for all tax-paid fuel purchases claimed on this line)
9
9
Gallons consumed with no tax paid – Subtract Line 8 from Line 7
10
10
Total gallons consumed with no tax paid – Add Columns A through D on line 9
TAX COMPUTATION
11
11
Total tax-unpaid gallons – Record amount from Line 10 here
12
12
$0.20
Tax Rate
13
13
$
Total Fuel Tax Due – Multiply Line 11 by Line 12
14
14
Total gallons used for off-road commercial use or for heating purposes (Subject to Sales Tax)
15
15
$
Total Sales Tax Due – Complete Sales Tax Worksheet on reverse
16
16
$
Total Tax Liability – Add Line 13 and Line 15
17
17
$
Interest and/or Penalty (If filing after due date)
18
18
$
Balance Due or Credit from prior records (See Computer Notice)
19
19
$
Total Remittance – Add Lines 16 and 17, and add or subtract Line 18 (Depending on balance due or credit)
I declare and affirm under the penalty of perjury that this report has been examined by me, and to the best of my knowledge and belief is in all things true
and correct.
Signature
Title
Date
DOR/DMV FORM 572 (04/97)
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