Form Gas 1301 - Common&contract Petroleum Products Carrier Return - State Of North Carolina

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Form Gas 1301
MFD
(Rev. 6/98)
NORTH CAROLINA DEPARTMENT OF REVENUE
MOTOR FUELS TAX DIVISION
(Web)
P. O. BOX 25000 RALEIGH, N.C. 27640
TELEPHONE: (919) 733–3409 FAX: (919) 733–8654
RETURN FOR MONTH OF
19
COMMON & CONTRACT PETROLEUM PRODUCTS CARRIER RETURN
Required pursuant to the Laws of the State of North Carolina
To be filed Monthly by the 25th day after the End of Each Month
FAX:
COUNTY:
CARRIER NAME:
ACCOUNT NUMBER:
MAILING ADDRESS:
CITY:
STATE:
ZIP CODE:
TELEPHONE NUMBER: (
)
LINE
DESCRIPTION
NET GALLONS
TOTAL GALLONS OF PETROLEUM PRODUCT LOADED AT A NORTH CAROLINA TERMINAL OR BULK PLANT
1
AND DELIVERED TO ANOTHER STATE (ATTACH SCHEDULE 1A).
TOTAL GALLONS OF PETROLEUM PRODUCT LOADED AT AN OUT–OF–STATE TERMINAL OR BULK PLANT
2
AND DELIVERED IN NORTH CAROLINA (ATTACH SCHEDULE 2A).
TOTAL GALLONS OF PETROLEUM PRODUCT LOADED AT A NORTH CAROLINA TERMINAL OR BULK
3
PLANT AND DELIVERED IN NORTH CAROLINA.
NOT BEING REQUIRED AT THIS TIME
4
TOTAL GALLONS OF PETROLEUM PRODUCT TRANSPORTED (LINE 1 + LINE 2 + LINE 3)
THE PENALTY FOR FILING THE RETURN LATE IS $50.00. PLEASE INDICATE AMOUNT PAID FOR
LATE FILING.
CERTIFICATE OF TAXPAYER
This is to certify that this return, including all statements and schedules attached hereto, has been examined by me, and is, to the
best of my knowledge and belief, a true and complete report made in good faith covering the month named and that same is in
accordance with the books and reports of the reporting taxpayer.
Date
Signed
Title
Report must be signed by owner of business, or if a partnership by a partner, or if a corporation by an authorized agent or corporate officer.

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