Form Mfd 1-S/af - Motor Fuel & Aviation Fuel Distributor Report - Department Of Safety - New Hampshire Page 8
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10MOTOR FUEL & AVIATION FUEL DISTRIBUTOR REPORT
Schedule of Disbursements
General Instructions
This form is required by RSA 260:38, I and is designated as forms MFD 5, 5X, 6, 6F, 7, 8 & 9. This form is to be completed by an authorized
representative. This schedule provides detail in support of the amount shown as disbursements on the Motor Fuel & Aviation Fuel Distributor Report.
Each disbursement of product should be listed on separate lines.
Identifying Information
Company Name, License Number and FEIN: Enter the name and numbers for the distributor shown on the distributor report.
Schedule type: A separate page is required for each schedule type. Enter one of the following schedule codes:
5
Gallons delivered – taxable
5X
Gallons delivered to Air Carriers taxable at a lower tax rate
6
Gallons delivered to NH licensed distributors
6F
Gallons of dyed diesel and dyed kerosene sold for tax exempt purposes
7
Gallons exported
8
Gallons delivered to US Gov‟t (Bulk) tax exempt
9
Gallons delivered to State/Local Gov‟t (Bulk) tax exempt
Product type: A separate page is required for each product type. Enter one of the following product codes (applicable product category is shown):
B99
Biodiesel blend 99%
065
Gasoline
D00
Biodiesel 100% - dyed
Automotive
E00
Ethanol – 100%
Special
D01
Biodiesel blend 1% - dyed
Gasoline
E10
Ethanol blend – 10%
Fuel
D05
Biodiesel blend 5% - dyed
E85
Ethanol blend – 85%
D20
Biodiesel blend 20% - dyed
072
Kerosene – dyed
D99
Biodiesel blend 99% - dyed
142
Kerosene – undyed
Aviation
125
Aviation Gasoline
160
Diesel Fuel – undyed
Gasoline
Special
228
Diesel Fuel – dyed
Jet Fuel
130
Jet Fuel
Fuel
B00
Biodiesel 100%
B01
Biodiesel blend 1%
B05
Biodiesel blend 5%
B20
Biodiesel blend 20%
Column Instructions
Columns (1) & (2)
Carrier-Enter the name and FEIN of the company that transports the product. The term “various” or other
generic terms is not acceptable.
Column (3)
Mode of Transport-Enter the mode of transport. Use one of the following:
J = Truck
R = Rail
B = Barge
PL = Pipeline
S = Ship
BA = Book Adjustment
ST = Stationary Transfer
GS = Gas Station
RT = Removal from terminal (other than by truck or rail for sale or consumption)
Column (4)
Point of Origin/Destination - Enter the location the product was transported from/to (City, State). When
disbursements are received from a terminal, use uniform terminal codes.
Column (5) & (6)
Purchaser -Enter the name and FEIN of the company that purchases the product. The term “various” or
other generic terms is not acceptable.
Column (7)
Date Delivered - Enter the date the product was delivered.
Column (8)
Document Number - Enter the identifying number from the manifest issued at the terminal when product was
removed over the rack. In the case of pipeline or barge movements, it is the pipeline or barge ticket number.
Column (9)
Gallons - Enter the gross gallons disbursed.
Column (10)
Gallons - Enter the net gallons disbursed.
Provide a Page Total for Columns 9 and 10 on each page. Provide a Product Total for each schedule type and product type on the last page of
each product type for that schedule. Carry the total of product totals for gross gallons for each product category forward to the appropriate
disbursements line on the Motor Fuel & Aviation Fuel Distributor Report.
RSA 260:38, I Provides that “For the purpose of determining the amount of road toll imposed and to be collected under this
subdivision, each distributor shall on or before the twentieth day of each calendar month render a return to the department on forms
prescribed and furnished by the commissioner. The return shall show the total number of gallons sold and used in the state during
the previous calendar month together with such other information as the commissioner may require for the reasonable
administration of this subdivision. Each distributor shall accompany the return with a check payable to the state treasurer for the
total amount of road toll shown by such return to be due.”
Tabulated computer listings containing all of the required schedule data may be used, but must be attached to the proper schedule.
FORMS MFD 5, 5X, 6, 6F, 7, 8, 9 (Revised 03/2010)
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