Schedule Df-1a - Receipt Record - Diesel Fuel/propane/natural Gas - State Of Connecticut - Department Of Revenue Services
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1Department of Revenue Services
Receipts Record
State of Connecticut
Schedule DF-1A
(Rev. 08/03)
Month of
Diesel Fuel / Propane / Natural Gas
Name of Licensed Distributor
Applicable Line Number on
Form OP-216
Connecticut Tax Registration Number
Instructions
• Use this schedule to provide data for completing Lines 2, 3, 4 and 5 on Form OP-216, Diesel Fuel / Propane / Natural Gas Tax Return .
• Prepare a separate schedule for each line as required.
• Insert applicable line number in the space provided.
• Attach completed schedule to Form OP-216.
CT Tax Paid
CT Tax Unpaid
Total
Date
Name of Supplier
Method of Delivery *Type of Fuel
Gallons
Gallons
(Round to nearest
whole gallon)
(1)
(2)
(3)
(4)
(5)
(6)
(7)
Total Gallons (Transfer this total to the aproppriate Line on Form OP-216, Diesel Fuel / Propane / Natural Gas Tax Return )
* Indicate type of fuel, such as, diesel fuel, #2 fuel oil, propane, natural gas, or kerosene blended with diesel fuel.
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