Form Ifta-100-Mn - Quarterly Fuel Tax Return - 2003
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1
2IFTA-100-MN
Georgia Department of Revenue
Motor Fuel Tax Unit Suite 9227
(Rev. 03/03)
1800 Century Center Blvd NE
Atlanta, Georgia 30345-3205
Use this form to report operations for the
Telephone No. (404) 417-6712
quarter ending
M
M
D
D
Y
Y
For Office Use Only
Sig
Cor
Name/ID
This report must be filed by the last day of the month
GA
following the end of the quarter
License IFTA Identification Number
Address
GA
No operation in any
Name
jurisdiction
Cancel License
Street Address
Amended Report
City
State
Zip code
IFTA Quarterly Fuel Use Tax Report
File this report even if there is no tax due.
Use this form filing your Quarterly Fuel Use Tax Report as required under the International Fuel Tax Agreement (IFTA).
Read the instructions on page 2 carefully. Make a copy of this report for your records.
Attach check or money order payable to:
Enter the amount of your payment here
Georgia Department of Revenue
$
See mailing instructions on page 2
Enter the Total from Column Q for Form IFTA-101-MN, IFTA Quarterly Fuel Use Tax Schedule, for fuel types listed in lines
1 thru 4. For all other fuel types enter the Total Amount from Column S of the worksheet on the back of Form IFTA-101-MN.
Enter any credit amounts in brackets. Attach a Form IFTA-101-MN for each fuel type reported below.
1. Diesel ....................................................................................................................................
1.
2. Motor Fuel Gasoline .............................................................................................................
2.
3. Ethanol..................................................................................................................................
3.
4. Propane (LPG) ......................................................................................................................
4.
5. All other fuel types not listed in lines 1 thru 4
.........
5.
(from worksheet on the back of IFTA-101-MN)
6. Subtotal of amount due or (credit) (add lines 1 thru 5).........................................................
6.
7. Penalty (see instructions) ......................................................................................................
7.
8. Total balance due or (credit) (add lines 6 and 7) ..................................................................
8.
9. Credit to be applied...............................................................................................................
9.
10. Balance due/(credit) (subtract line 9 from line 8) .................................................................
10.
11. Refund amount requested .....................................................................................................
11.
I certify that this business is duly licensed and that this report, including any schedules, is to the best of my knowledge and belief true, correct and complete.
Authorized Signature
Date
Taxpayer’s phone number
Official Title
Paid Preparer’s EIN
Paid Preparer’s name or firm
Paid Preparer’s phone number
(if other than taxpayer)
Paid Preparer’s address
Paid Preparer’s signature
Date
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