Form Boe-501-Ps (S1) - Supplier Of Motor Vehicle Fuel Tax Return Page 8

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STATE OF CALIFORNIA
BOE-501-PS (S5) REV. 5 (7-07)
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)
(7)
(8)
(9)
(11)
(3)
(6)
(10)
POINT OF
ACQUIRED FROM
DOCUMENT
CARRIER
CARRIER
MODE
SELLER'S
DOCUMENT
NET
GROSS
BILLED
FEIN
(Seller's Name)
DATE
NUMBER
GALLONS
GALLONS
FEIN
GALLONS
NAME
ORIGIN
DESTINATION
(TCN or
(TCN or
State/Province)
State/Province)
TOTAL

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