Form Mfd 1-S/af - Motor Fuel & Aviation Fuel Distributor Report - Department Of Safety - New Hampshire Page 2
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10Page 2 MFD 1-S/AF (Revised 03/2010)
NAME:
MONTH OF:
YEAR:
LICENSE NUMBER:
FEIN:
SECTION I
From
AUTOMOTIVE
SPECIAL
AVIATION
JET FUEL
Schedule
GASOLINE
FUEL
GASOLINE
RECEIPTS: (See Instructions)
1. Gallons received from NH licensed distributors in NH for
2
NH bulk storage
2. Gallons received from NH licensed distributors in NH for
2E
export
3. Gallons received from NH licensed distributors in NH
2F
and direct shipped to customers
4. Gallons imported from another state direct to
3
customer
5. Gallons imported from another state into NH bulk
4
storage
6. Total Receipts (Total lines 1 through 5) (Total to Page 1, Line 2)
JET FUEL
SECTION II
From
AUTOMOTIVE
SPECIAL
AVIATION
FAR PART 121
PRIVATE AND
Schedule
GASOLINE
FUEL
GASOLINE
DISBURSEMENTS: (See Instructions)
AIR CARRIERS
COMMERCIAL
1. Gallons delivered – taxable
5
2. Gallons delivered to Air Carriers taxable at
5X
a lower tax rate
3. Gallons delivered to NH licensed distributors
6
4. Gallons of dyed diesel and dyed kerosene
6F
sold for tax exempt purposes
5. Gallons exported
7
6. Gallons delivered to US Gov‟t (Bulk)
8
tax exempt
7. Gallons delivered to State/Local
9
Gov‟t (Bulk) tax exempt
8. Total Disbursements (Total Lines 1 through 7) (Total to
Page 1, Line 4)
9. Total Taxable Gallons (Total Lines 1 through 2) (Total to
Page 1, Line 8)
JET FUEL
SECTION III
From
AUTOMOTIVE
SPECIAL
AVIATION
FAR PART 121
PRIVATE AND
Schedule
GASOLINE
FUEL
GASOLINE
TAX-PAID CREDITS: (See Instructions)
AIR CARRIERS
COMMERCIAL
1. Retail Sales to US Gov‟t and their
13C
agencies
2. Retail Sales to Local or State Gov‟t and their
13H
agencies
3. Retail Sales to State, Local or US Gov‟t and their
13K
agencies at the Air Carriers rate
4. Total tax-paid credits (Total Lines 1 through 3) (Total to
Page 1, Line 9)
MFD 1-S/AF (Revised 03/2010)
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