Form Rpd-41179 - Wholesaler'S Gasoline And Ethanol Blended Fuel Tax Report

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RPD - 41179
REV. 07/99
WHOLESALER'S GASOLINE AND ETHANOL
BLENDED FUEL TAX REPORT
Report Month _________________ 19 ______
o ORIGINAL
o AMENDED
Please return report to:
New Mexico Taxation and Revenue Department
P.O. Box 25123
Santa Fe, NM 87504-5123
505-827-0764
INVENTORY RECONCILIATION
PURCHASES
SALES
The penalty for late filing is $5.00
Do not enclose penalty payment with this report. Penalty for late filing will be assessed separately.
I declare that I have examined this return, including any accompanying schedules and statements, and to the best of my knowledge and belief
it is true, correct and complete.
Date
Signature of Authorized Agent
Title
Phone Number

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