Form Rmft-6-Sf - Schedule Sa - Mft, Ust, And Eif Special Fuel (Excluding Dyed Diesel Fuel) Produced, Acquired, Received, Or Transported Into Illinois (1999)

Illinois Department of Revenue

MFT, UST, and EIF

Page ____ of ____

Schedule SA

Special Fuel (Excluding Dyed Diesel Fuel)

Produced, Acquired, Received, or Transported into Illinois

Attach to Form RMFT-5 or Form RMFT-5-US

Step 1: Complete the following information

______________________________________________

Check the tax/fee type you are listing on this page.

Check the receipt type that you are listing on this page.

Company name

MFT-free only

Received in Illinois

______________________________________________

UST-/EIF-free only

Imported into Illinois

Your license number

Reporting period __ __/__ __ __ __

Both MFT- and UST-/EIF-free

Produced in your Illinois refinery

Month

Year

Step 2: Report your tax- and fee-free purchases

Invoice date

Invoice

Name of

Bill of lading or

Origin

Destination

Seller’s

Invoiced

(month, day, year)

number

carrier

manifest number

Name of seller

(city and state)

(Illinois cities only)

license number

gallons

_ _/_ _/_ _ _ _ _________________________________ ___________________________________________________________________________________ _________________

_ _/_ _/_ _ _ _ ________________________________ ___________________________________________________________________________________ _________________

_ _/_ _/_ _ _ _ ______________________________________________________________________________________________________________________________________

11 Add the invoiced gallons in Column 9, Lines 1 through 10, and write the total here.

________________

12 If you are filing only one Schedule SA, write the amount from Line 11 here.

________________

If you are reporting

• MFT-free gallons only, also write this amount on Form RMFT-5, Line 2a, Column 2.

• UST-/EIF-free gallons only, also write this amount on Form RMFT-5-US, Line 2a, Column 1.

• both MFT- and UST-/EIF-free gallons, also write this amount on Form RMFT-5, Line 2a, Column 2, and Form RMFT-5-US, Line 2a, Column 1.

If you are filing more than one Schedule SA, see instructions.

This form is authorized as outlined by the Motor Fuel Tax Law and the Environmental Impact Fee Law. Disclosure of this information is REQUIRED.

RMFT-6-SF front (R-12/99)

Failure to provide information could result in a penalty. This form has been approved by the Forms Management Center.