Gasoline Distributor'S Schedule Of Disbursements Form
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1Gasoline Distributor's Schedule of Disbursements
Company Name
Registration Number
FEIN
Schedule Type
Product Type
Month/Year
Schedule Types
Product Types
5 Gallons delivered to other distributors - tax collected
65 Gasoline
E00 100% Ethanol
M00 100% Methanol
6 Gallons delivered to licensed distributors - tax not collected
125 Aviation Gasoline
E01-E99 Ethanol Blend
M01-M99 Methanol Blend
7 Gallons exported to state of ___________________________
130 Jet Fuel
Enter Ethanol %: ____________
Enter Methanol %: ____________
8 Gallons delivered to U. S. Government - tax exempt
Other (use FTA product codes)
9 Gallons delivered to this State or political subdivisions
10 Gallons of jet fuel delivered for international flights
22 Dealer credit card sales to U.S. Government and dealer sales supported by 1094's
(1)
(2)
(3)
(4)
(6)
(7)
(8)
(9)
(5) Sold To
Carrier
Carrier
Point of
Purchaser's
Date
Document
Gross
Name
FEIN
Mode Origin
Dest.
FEIN
Shipped
Number
Gallons
Total
Transportation mode codes: J = Trucks, R = Railroad, B = Barge, PL = Pipeline, S = Ship or Barge, BA = Book Adjustment, ST = Stock Transfer
Reproduce as needed
GASDURS
Revised July 1, 2008
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Parent category: Financial