Form 81-015a - Schedule Of Disbursements Supplier, Restrictive Supplier, Importer And Blender

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I OWA
Schedule of Disbursements
d e p a r t m e n t of R eve nu e a n d F i n a n c e
Supplier, Restrictive Supplier, Importer and Blender
81-015a (04/02)
Company Name
License Number
FEIN:
Schedule Type:
Product Type:
Month/Year
Schedule Type:
Product Type (list in box above) Only one product per schedule.
1 Gallons Sold Iowa Tax-Paid
65 Gasoline
130 Jet Fuel
226 High Sulfur Diesel Fuel - dye added
3 Gallons Imported from another state direct to customer
123 Alcohol
142 Kerosene - Undyed
227 Low Sulfur Diesel Fuel - dye added
6 Gallons Delivered to Licensed Supplier - Tax NOT Collected
124 Gasohol
161 Low Sulfur No. 1 Diesel Fuel
284 Bio-diesel
6F Gallons Delivered - Tax NOT Collected - Dye Added
125 Aviation Gasoline
167 Low Sulfur No. 2 Diesel Fuel
285 Soy Oil
7 Gallons Exported (or sold for export) to State of ________________
___ Other (see FTA Product Code List)
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
Point Of
Purchaser
Purchaser
Purchase
Bills Of
Carrier Name
Carrier FEIN
Mode
Origin
Dest.
Name
FEIN
Date
Lading
Gross Gallons
Totals:

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