Form Boe-501-Dd - Supplier Of Diesel Fuel Tax Return - State Of California Page 7

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BOE-501-DD (S5) REV. 4 (4-03)
STATE OF CALIFORNIA
BOARD OF EQUALIZATION
RECEIPT SCHEDULE
(If additional space is needed, please photocopy the schedule before making entries.)
Page
of
(a) COMPANY NAME
(b) ACCOUNT NUMBER
(c) SCHEDULE CODE
(d) PRODUCT CODE
(e) MONTH/YEAR
(4)
(5)
(1)
(2)
(3)
(6)
(7)
(8)
(9)
(10)
(11)
POINT OF
ACQUIRED FROM
CARRIER
MODE
SELLER'S
DOCUMENT
DOCUMENT
NET
GROSS
BILLED
CARRIER
(Seller's Name)
FEIN
FEIN
DATE
NUMBER
GALLONS
GALLONS
GALLONS
NAME
ORIGIN
DESTINATION
(TCN or
(TCN or
State/Province)
State/Province)
TOTAL

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