Form Mfd 1-S/af - Motor Fuel & Aviation Fuel Distributor Report - Department Of Safety - New Hampshire
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10FOR OFFICIAL USE ONLY
STATE OF NEW HAMPSHIRE
DEPARTMENT OF SAFETY
Postmark Date:
ROAD TOLL BUREAU
Audited By:
33 HAZEN DRIVE, CONCORD NH 03305
Audit Date:
TELEPHONE: (603)271-2311
Verified By:
Verified Date:
MOTOR FUEL & AVIATION FUEL DISTRIBUTOR REPORT
NAME:
MONTH OF:
YEAR:
REPORT MUST BE POSTMARKED NO LATER THAN THE 20
DAY OF THE MONTH
ADDRESS 1:
TH
FOLLOWING THE REPORTING PERIOD
ADDRESS 2:
TELEPHONE NUMBER:
CITY/TOWN:
LICENSE NUMBER:
STATE:
ZIP CODE:
FEIN:
INVENTORIES, RECEIPTS &
AUTOMOTIVE
SPECIAL
AVIATION
JET
GASOLINE
FUEL
GASOLINE
FUEL
DISBURSEMENTS
1. Beginning Physical Inventory
(must agree with prior month‟s ending inventory)
2. Receipts: (from Page 2, Section 1, Line 6)
3. Gallons of biodiesel refined, distilled, blended or
manufactured
4. Disbursements: (from Page 2, Section II, Line 8)
5. Transfers (from one product to another)
6. Gain or (Loss) (attach explanation)
7. Ending Physical Inventory
(must agree with actual ending inventory)
JET FUEL
AUTOMOTIVE
SPECIAL
AVIATION
TAX COMPUTATION
FAR PART 121
PRIVATE AND
GASOLINE
FUEL
GASOLINE
AIR CARRIERS
COMMERCIAL
8. Taxable Gallons (from Page 2, Section II, Line 9)
9. Gallons of tax-paid credits (from Page 2, Section III,
Line 4)
10. Net taxable gallons (Line 8 – Line 9)
$0.18
$0.18
$0.04
$0.005
$0.02
11. Tax Rate Per Gallon
12. Tax Due By Product (Line 10 times Line 11)
TOTAL TAX DUE
13. Total Tax Due (Total all columns in Line 12)
14. Penalty (See Instructions)
15. Interest (See Instructions)
16. TOTAL AMOUNT DUE
(add Lines 13, 14 and 15)
Name:
Signature:
(Please Print)
Title:
Date:
“THIS APPLICATION IS SIGNED UNDER PENALTY OF UNSWORN FALSIFICATION PURSUANT TO RSA 641:2"
MAKE CHECKS PAYABLE TO: STATE OF N.H.-ROAD TOLL BUREAU
MFD 1-S/AF (Revised 03/2010)
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