Form Rev-1096b Mf - Liquid Fuels And Fuels Tax Report Receipts And Disbursements Summary - 2007
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1COMMONWEALTH OF PENNSYLVANIA
Pennsylvania Department of Revenue
DEPARTMENT OF REVENUE
Liquid Fuels and Fuels Tax Report
BUREAU OF MOTOR FUEL TAXES
Receipts and Disbursements Summary
PO BOX 280646
(SEE INSTRUCTIONS ON REVERSE SIDE)
HARRISBURG PA 17128-0646
TELEPHONE (717) 783-9355
REV-1096B MF (11-07)
DISTRIBUTOR’S NAME:
FEIN:
TAX PERIOD:
Section I. - Receipts:
Item
From
Gasoline
Diesel, Biodiesel
Jet Fuel
Aviation
Schedule
and
and
Gas
Gasohol
Kerosene
1.
PA Refinery Production
XXXXXXX
2.
Gallons Received PA Tax Paid and
Placed in Inventory
1
3.
Gallons Received PA Tax Paid and
Direct Shipped to Customers
1F
4.
Gallons Received Tax Free
(From other PA registered distributors)
2
5.
Gallons Received Tax Free and
Direct Shipped to Customers
2F
6.
Gallons Imported & Direct Shipped
to PA Customers
3
7.
Gallons Imported into
Storage in PA
4
8.
Total Receipts
XXXXXXX
Section II. - Disbursements:
Item
From
Gasoline
Diesel, Biodiesel
Jet Fuel
Aviation
Schedule
and
and
Gas
Gasohol
Kerosene
1.
Gallons Delivered Tax Collected
(Taxable Sales)
5
2.
Taxable Use
5Q
3.
Gallons Delivered Tax Free to
PA Distributors (Resales)
6
4.
Gallons Exported
7
5.
Gallons Delivered Tax Exempt to
U.S. Gov’t
8
6.
Gallons Delivered Tax Exempt to PA
and its Political Subdivisions
9
7.
Gallons Delivered Tax Exempt to
Other Exempt Entities
10
8.
Total Disbursements
XXXXXXX
1096207100
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