STATE OF NEW MEXICO - TAXATION AND REVENUE DEPARTMENT
FUELS TAX UNIT
DISTRIBUTORS SCHEDULE OF PURCHASES
SCHEDULE TYPE (Check One)
Taxpayer Identification Number
Schedule A, Gallons Received at rack, Produced or Blended
Distributor's Name
Schedule B, Gallons Imported from State of
Schedule C, Gallons received when transported off Indian Land
Month/Year
Schedule D, Other Gallons Purchased
NM Tax
Business
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Document
Tax Excluded
Tax Included
Identification Number
Name
Point
Date
Number
Gallons
Gallons
TOTALS
FORM GTX15C rev 06/00