Motor Fuel Distributor'S Tax Return Form - State Of Rhode Island Division Of Taxation Page 2
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3STATE OF RHODE ISLAND
DIVISION OF TAXATION
MOTOR FUEL TAX
MULTIPLE SCHEDULES OF RECEIPTS
USE SEPARATE FORM FOR EACH SCHEDULE AND PRODUCT
SCHEDULE
________________________________
NAME OF DISTRIBUTOR ________________________________
PRODUCT
________________________________
MONTH / YEAR
________________________________
TYPE OF SCHEDULE
PRODUCT CODE
2 GALLONS RECEIVED / IMPORTED FROM SOURCES OUTSIDE THIS STATE
3 GALLONS RECEIVED FROM SOURCES WITHIN THIS STATE
A. GASOLINE
D. JET FUEL
4 GALLONS RECEIVED IN THIS STATE AND SHIPPED DIRECTLY TO CUSTOMERS IN OTHER STATES
B. ALCOHOL / GASOLINE
E. DIESEL FUEL
5 GALLONS RECEIVED IN THIS STATE AND SHIPPED DIRECTLY TO CUSTOMERS IN THIS STATE
C. AVIATION GASOLINE
F. OTHER ( IDENTIFY )
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2
3
4
5
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DATE
NAME OF
ACQUIRED
INVOICE OR
BILLED
ORIGIN
DESTINATION
MM/DD/YY
CARRIER
FROM
DOCUMENT No.
GALLONS
ALL COLUMNS MUST BE COMPLETED FOR EACH TRANSACTION
TOTAL
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