Form Gas-1239 - Motor Fuel Monthly Bulk Plant Exporter Return - 2004
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1GAS-1239
Motor Fuel Monthly Bulk Plant Exporter Return
Web
North Carolina Department of Revenue
1-04
MFD
Legal Name (First 36 Characters) (USE CAPITAL LETTERS FOR YOUR NAME AND ADDRESS)
Fill in applicable circles:
Address has changed since prior return
Trade Name
Amended return
Final return for closed business
Street Address
County
FEIN or SSN
(No dashes)
Mailing Address
-
70
Zip Code (First 5 digits)
City
State
Return for Month of
-
Name of Contact Person
Phone Number
Fax Number
(
)
(
)
(Month)
(Year)
Computation of Tax
Gasoline
Diesel Fuel
Undyed Kerosene
Dyed Kerosene
Jet Fuel
AvGas
Total
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7
1 2 3 4 5 6 7 8 9 0 1 2 3 4
1 2 3 4 5 6 7 8 9 0 1 2 3
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7
1 2 3 4 5 6 7 8 9 0 1 2 3 4
1 2 3 4 5 6 7 8 9 0 1 2 3
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7
1 2 3 4 5 6 7 8 9 0 1 2 3 4
1 2 3 4 5 6 7 8 9 0 1 2 3
1.
Total untaxed gallons of motor
.0
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7
1 2 3 4 5 6 7 8 9 0 1 2 3 4
1 2 3 4 5 6 7 8 9 0 1 2 3
.0
.0
fuel exported from bulk plant
1.
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7
1 2 3 4 5 6 7 8 9 0 1 2 3 4
1 2 3 4 5 6 7 8 9 0 1 2 3
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7
1 2 3 4 5 6 7 8 9 0 1 2 3 4
1 2 3 4 5 6 7 8 9 0 1 2 3
(Gas-1239ES, Schedule 7E, Column 12)
2.
Tax-paid gallons of motor fuel
.0
.0
.0
.0
.0
.0
.0
exported from bulk plant
2.
(Gas-1239ES, Schedule 7F, Column 12)
3.
Total gallons of motor fuel
.0
.0
.0
.0
.0
.0
.0
exported from bulk plant
3.
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7
1 2 3 4 5 6 7 8 9 0 1 2 3 4
1 2 3 4 5 6 7 8 9 0 1 2 3
(Add Lines 1 and 2)
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7
1 2 3 4 5 6 7 8 9 0 1 2 3 4
1 2 3 4 5 6 7 8 9 0 1 2 3
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7
1 2 3 4 5 6 7 8 9 0 1 2 3 4
1 2 3 4 5 6 7 8 9 0 1 2 3
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7
1 2 3 4 5 6 7 8 9 0 1 2 3 4
1 2 3 4 5 6 7 8 9 0 1 2 3
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7
1 2 3 4 5 6 7 8 9 0 1 2 3 4
1 2 3 4 5 6 7 8 9 0 1 2 3
4.
Motor fuels road tax refund due
4.
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7
1 2 3 4 5 6 7 8 9 0 1 2 3 4
1 2 3 4 5 6 7 8 9 0 1 2 3
(Multiply Line 2 by road tax rate)
5.
Motor fuels inspection tax refund
due
5.
( Add Line 1 (Diesel fuel only) and Line
2 then multiply by $0.0025)
6.
Tare allowance received
(If a Licensed Distributor, add Lines 4 and
6.
5 and then multiply that total by 0.01. If
not a Licensed Distributor, enter zero)
$
7.
Total Refund Due
7.
(Add Lines 4 and 5 then subtract Line 6)
Title:
Signature:
Date:
To the best of my knowledge, this return is accurate and complete.
I certify that:
Tax has been or will be timely paid to the destination state of the motor fuel exported during the month.
Returns are due by the 25th of each month.
QUESTIONS:
MAIL TO:
Contact the Motor Fuels Tax Division at:
North Carolina Department of Revenue
Telephone Number
(919) 733-3409
Motor Fuels Tax Division
Post Office Box 25000
Toll Free Number
(877) 308-9092
Raleigh, North Carolina 27640-0950
Fax Number
(919) 733-8654
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