Form Rmft-16 Schedule La - Ust And Eif Fuels Other Than Gasoline Products And Special Fuels Produced, Acquired, Received, Or Transported Into Illinois
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1Illinois Department of Revenue
UST and EIF
Page ____ of ____
Schedule LA
Fuels Other Than Gasoline Products and Special Fuels
Produced, Acquired, Received, or Transported into Illinois
Attach to Form RMFT-5-US
Step 1: Complete the following information
______________________________________________
Check the receipt type you are listing on this page.
Company name
Other fuel products received in Illinois
______________________________________________
Other fuel products imported into Illinois
Your license number
Reporting period __ __/__ __ __ __
Other fuel products produced in your Illinois refinery
Month
Year
Step 2: Report your tax- and fee-free purchases
1
2
3
4
5
6
7
8
9
10
Invoice date
Invoice
Name of
Bill of lading or
Product
Origin
Destination
Seller’s
Invoiced
number
carrier
manifest number
code
Name of seller
(city and state)
(Illinois cities only) license number
gallons
(month, day, year)
(see instr.)
1
_ _/_ _/_ _ _ _ _____________________________________________________________________________________________________________________________________
2
_ _/_ _/_ _ _ _ _____________________________________________________________________________________________________________________________________
3
_ _/_ _/_ _ _ _ _____________________________________________________________________________________________________________________________________
4
_ _/_ _/_ _ _ _ _____________________________________________________________________________________________________________________________________
5
_ _/_ _/_ _ _ _ _____________________________________________________________________________________________________________________________________
6
_ _/_ _/_ _ _ _ _____________________________________________________________________________________________________________________________________
7
_ _/_ _/_ _ _ _ _____________________________________________________________________________________________________________________________________
8
_ _/_ _/_ _ _ _ _____________________________________________________________________________________________________________________________________
9
_ _/_ _/_ _ _ _ _____________________________________________________________________________________________________________________________________
10
_ _/_ _/_ _ _ _ _____________________________________________________________________________________________________________________________________
11 Add the invoiced gallons in Column 10, Lines 1 through 10. Write the total amount here.
11
________________
12 If you are filing only one Schedule LA, write the amount from Line 11 here and on Form RMFT-5-US, Line 2a, Column 2.
12
________________
If you are filing more than one Schedule LA, add Line 11 from each schedule, and write the total on Line 12 of the last page.
Also write this amount on Form RMFT-5-US, Line 2a, Column 2.
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-16 front (R-02/00)
Failure to provide information could result in a penalty. This form has been approved by the Forms Management Center.
IL-492-2311
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