Motor Fuel Distributor'S Tax Return Form - State Of Rhode Island Division Of Taxation
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1
2
3STATE OF RHODE ISLAND
DIVISION OF TAXATION
ONE CAPITOL HILL PROVIDENCE RI 02908
MOTOR FUEL DISTRIBUTOR'S TAX RETURN
MONTH OF ______________________________
DISTRIBUTOR NAME
MAILING ADDRESS
CITY/TOWN/STATE/ZIP CODE
GASOLINE
DIESEL
1. Opening Inventory ( including in transit)
1
2. Gallons Received / Imported From Sources Outside This State
2
3. Gallons Received From Sources Within This State
3
4. Gallons Received in This State and Shipped Directly to Customers in Other States
4
5. Gallons Received in This State and Shipped Directly to Customers in This State
5
6. Total Changes (Add items 1 through 5 )
6
7. Less Closing Inventory (including in transit)
7
8. Total Gallons
8
9. Gallons Sold or Delivered Out of Rhode Island
9
10. Gallons Sold to Licensed Exporters
10
11. Gallons Sold to Licensed Distributors
11
12. Gallons Sold to United States Government
12
13. Other Non-Taxable Distribution
13
14. Gain or Loss (show gain on red and deduct)
14
15. Total Non-Taxable Distribution
15
16. Taxable Sales
16
17. Taxable Gallons Consumed or Used
17
18. Total Taxable Distribution
18
19. Total Gallons (Add items 15 and 18)
19
GALLONS
AMOUNT
20.Total Taxable Distribution ( Multiply Totals on Line 18 By Current Rate)
20
$
21. Less Dealer Sales to U.S. Government
21
$
22. Total Taxable Distribution ( Line 20 Less Line 21 )
22
$
23. Add or Deduct Adjustments On Previous Months Return
23
$
24. Adjusted Taxable Distribution ( Line 22 Plus or Minus Line 23 )
24
$
25. Motor Fuel Tax Due ( Multiply Line 24 By Current Rate )
25
$
The undersigned ______________________________________________________________________of
Name
Title
______________________________________________________________________________________hereby certifies that he/she is
Distributor
properly authorized to sign this return, that he/she has personal knowledge of the figures and information constituting this return,
and that the schedules and statements herein contained are true and complete to the best of his/her knowledge and belief.
The undersigned hereby declares that this return is made under penalties of perjury.
Date______________________Signature ________________________________________________Title________________
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