Form 72a234 - Licensed Special Fuels Dealer'S Monthly Report Of Dyed Diesel Sales To U.s. Government
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172A234 (7-00)
LICENSED SPECIAL FUELS DEALER’S MONTHLY REPORT
Commonwealth of Kentucky
OF DYED DIESEL SALES TO U.S. GOVERNMENT
REVENUE CABINET
Name and Address of Dealer
INSTRUCTIONS: This report must be completed when dyed diesel
is sold to the U.S. government, its agencies or instrumentalities for
Report for Month of
use exclusively in equipment or vehicles owned or leased by the U.S.
government. Return completed report to Revenue Cabinet, Frankfort,
___________________________ , 20______
Kentucky 40620.
Contract
Invoice
Number
Name and Address of
Name and Title
Function of Agency
Date
Number
of Gallons
Federal Agency
of Authorized Purchaser
Number
TOTAL*
*Total sales to U.S. government must equal amount reported on Form 72A200.
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Parent category: Financial