Rack Operator Report Form - 2005
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1State of New Mexico - Taxation & Revenue Department
RPD-41307
RACK OPERATOR REPORT
INT. 12/2005
Original
Amended
REPORT FOR THE MONTH OF ____________________, __________
Please send report to:
TERMINAL
New Mexico Taxation & Revenue Dept.
Name of Terminal:
Terminal Code:
Special Tax Programs & Services
P O Box 25123
Location of Terminal:
Santa Fe, NM 87504-5123
Phone 505-827-0765
OPERATOR
Name:
FEIN / SSN / BN:
CRS ID:
Phone #:
Address:
City:
State
Zip Code:
Transactions For The Month
Net Gallons
Schedule
Number
Gasoline Products
Special Fuel Products
Other Products
Gallons sold to Registered Distributors or Suppliers
6
1
Gallons sold/purchased through exchange agreements
2
6X
Gallons exported directly outside of New Mexico
3
7
Gallons sold and shipped directly to Reg. Indian Tribal Dist. on Indian Land
4
10
Gallons sold and shipped directly to other than Registered Indian Tribal
5
10A
Distributors on Indian land
*
Return is due by the 25th of the month following the report month.
I declare that I have examined this return, including any accompanying schedules and statements,
and to the best of my knowledge and belief it is true, correct and complete.
Signature of Authorized Agent
Title
Date
_________________
____________________
_______________________
Printed Name of Agent
Telephone #
Fax #
Email Address
RPD41307
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