Form 06-168 - Texas Fuels Tax Report 2004 Page 3
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406-168-B
BBBB
(Rev.11-04/2)
b.
a.
06101 Gasoline Exporter
Please do not write in space above
e. Filing period
f.
TEXAS FUELS TAX REPORT - Page 2
--For 2004 and later
c. Taxpayer number
d. Taxpayer name
ENTER WHOLE GALLONS
SECTION II - DISBURSEMENTS
(See instructions)
XXXXXXXXXXXXXXXXXXX
10. Blended gallons sold
(from attached Schedule, Form 06-152)
10.
XXXXXXXXXXXXXXXXXXX
11. Gallons sold to unlicensed entities in the bulk transfer/terminal system -- tax
collected by supplier/permissive supplier
(from attached Schedule, Form 06-153)
11.
12. Gallons removed from IRS Registered Terminal including deliveries to
XXXXXXXXXXXXXXXXXXX
company owned stores - tax collected by supplier/permissive supplier
12.
(from attached Schedule, Form 06-154)
XXXXXXXXXXXXXXXXXXX
13. Gallons of dyed diesel fuel sold tax free to license holders or removed
from IRS registered terminal
(from attached Schedule, Form 06-155)
13.
XXXXXXXXXXXXXXXXXXX
14. Gallons sold tax-free to aviation fuel dealers
14.
(from attached Schedule, Form 06-156)
15. Gallons exported
(from attached Schedule, Form 06-157)
15.
XXXXXXXXXXXXXXXXXXX
16. Gallons sold tax-free for export
(from attached Schedule, Form 06-158)
16.
17. Gallons sold tax-free to exempt entities
(from attached Schedule, Form 06-159)
17.
XXXXXXXXXXXXXXXXXXX
18. Gallons of dyed diesel fuel sold on a signed statement
18.
(from attached Schedule, Form 06-160)
XXXXXXXXXXXXXXXXXXX
19. Other tax-free sales and uses of dyed diesel fuel
19.
(no schedule)
20. Taxable sales and uses of dyed diesel fuel and gallons subject to backup tax
20.
(no schedule)
21. State diversions of undyed diesel fuel/gasoline (plus or minus)
(from attached Schedule, Form 06-161)
21.
22. TOTAL FOR SECTION II
(Add Items 10 through 21)
22.
SECTION III - TAX CALCULATION
23. Taxable gallons
23.
(Total of Items 5, 11, 12, 20, and 21.)
XXXXXXXXXXXXXXXXXXX
24.
24. Gallons received in IRS registered terminal Texas tax paid
XXXXXXXXXXXXXXXXXXX
25. Bad debts
(from attached Schedule, Form 06-163)
25.
26. Credit for gallons purchased tax-paid and sold tax-free
26.
27. Tax-paid gallons lost by fire, theft, or accident
27.
28. Other tax exempt uses on which Texas tax was previously paid
28.
29. Adjusted Taxable Gallons
29.
(Item 23 minus Items 24, 25, 26, 27, and 28)
30. Allowance for handling for the gallons on
XXXXXXXXXXXXXXXXXXX
which tax is timely paid
(Multiply Item 29 by
)
30.
31. Net taxable gallons
(Item 29 minus Item 30 plus Item 7)
31.
$
32. Total tax due
(Item 31 at
per gallon)
32.
Daytime phone (Area code and no.)
I declare that the information in this document and any attachments is true and correct to the
best of my knowledge and belief.
Officer, director, or authorized agent
Print or type name
Date
under Chapters 552 and 559, Government Code, to review, request, and correct information
You have certain rights
we have on file about you. Contact us at the address or toll-free number listed on this form.
REPORT MUST BE SIGNED FOR REFUND TO BE ISSUED.
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