Dor/dmv Form 573 - Marketer Refund Page 2
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1
2Reefer Storage Diesel Fuel Worksheet
On the worksheet below, list the gallons of reefer fuel sold for each date and indicate
the amount of sales tax you reported and remitted on your previous sales tax return.
Your total gallons for sales tax remitted should equal the amount recorded
on Line 5 on the first page of this refund form.
Record your sales tax license number here:
1
Gallons Undyed Diesel Fuel:
Sales Tax Remitted: $
Date (MM-YY):
2
Gallons Undyed Diesel Fuel:
Sales Tax Remitted: $
Date (MM-YY):
3
Gallons Undyed Diesel Fuel:
Sales Tax Remitted: $
Date (MM-YY):
4
Gallons Undyed Diesel Fuel:
Sales Tax Remitted: $
Date (MM-YY):
5
Gallons Undyed Diesel Fuel:
Sales Tax Remitted: $
Date (MM-YY):
6
Gallons Undyed Diesel Fuel:
Sales Tax Remitted: $
Date (MM-YY):
7
Gallons Undyed Diesel Fuel:
Sales Tax Remitted: $
Date (MM-YY):
8
Gallons Undyed Diesel Fuel:
Sales Tax Remitted: $
Date (MM-YY):
9
Gallons Undyed Diesel Fuel:
Sales Tax Remitted: $
Date (MM-YY):
10
Gallons Undyed Diesel Fuel:
Sales Tax Remitted: $
Date (MM-YY):
11
Gallons Undyed Diesel Fuel:
Sales Tax Remitted: $
Date (MM-YY):
12
Gallons Undyed Diesel Fuel:
Sales Tax Remitted: $
Date (MM-YY):
13
Gallons Undyed Diesel Fuel:
Sales Tax Remitted: $
Date (MM-YY):
Total
Total Gallons Undyed Diesel Fuel:
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