Form Gas-1209 - Motor Fuel Terminal Operator Annual Return

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GAS-1209
Motor Fuel Terminal Operator Annual Return
North Carolina Department of Revenue
1-09
Trade Name of Terminal
(USE CAPITAL LETTERS FOR YOUR NAME AND ADDRESS)
FOR OFFICE USE ONLY
Fill in applicable circles:
City
Street Address of Terminal
State
Zip Code (First 5 digits)
Amended return
Final return for closed business
Terminal Code
Legal Name of Terminal Operator
(First 45 Characters)
-
-
-
T
Mailing Address
Account Number
City
State
Zip Code (First 5 digits)
Return for Calendar Year
Name of Contact Person
Phone Number
Fax Number
2008
(
)
(
)
Aviation
Computation of Tax
Gasoline
Undyed Diesel
Dyed Diesel
Undyed Kerosene
Dyed Kerosene
Jet Fuel
Total
Gasoline
1.
Net gallons loss/<gain>
1.
(From total on Page 2)
2.
Total disbursements
2.
(From total on Page 2)
3.
Acceptable loss
3.
(Multiply Line 2 by .005)
4.
Taxable gallons
4.
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4
(Line 1 minus Line 3; if zero or less, enter zero)
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4
5.
Road tax due
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4
5.
(Multiply Line 4 by $0.2990)
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4
6.
Inspection tax due
6.
(Multiply Line 4 by $0.0025)
7.
Total road and inspection tax due
7.
(Add Line 5 & 6)
8.
Penalty for unaccounted for fuel
8.
(Enter amount from Line 7)
9.
Penalty
9.
(See Instructions)
10. Interest
10.
(See Instructions)
$
11. Total Amount Due
11.
(Add Lines 7 through 10)
MAIL TO:
QUESTIONS:
North Carolina Department of Revenue
Contact the Motor Fuels Tax Division at:
Motor Fuels Tax Division
Telephone Number
(919) 733-3409
Return is due by February 16, 2009.
Post Office Box 25000
Toll Free Number
(877) 308-9092
Any payment must be drawn on a U.S. (domestic) bank and payable in U.S. dollars.
Raleigh, North Carolina 27640-0950
Fax Number
(919) 733-8654

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Parent category: Financial
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