Form Sf-900 - Consolidated Special Fuel Monthly Tax Return - 2017 Page 2
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4Section 6: Signature Section
Under the penalty of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the
best of my knowledge and belief it is true, correct, and complete. I further declare that complete and proper records are on file at the
address indicated on the previous page for all fuel reported on this return.
Signature of Taxpayer or Authorized Agent: ____________________________________
Date:_____________________________
Typed or Printed Name: _____________________________
Title: __________________
Phone Number: __________________
Section A: Receipts
From Schedule
Use Whole Gallons Only
1 Gallons Received Tax Paid
1
2 Gallons Received for Export (To be completed only by licensed exporters)
2E
3 Gallons of Nontaxable Fuel Received and Sold or Used For a Taxable Purpose
2K
4 Gallons Imported Via Truck, Barge, or Rail, Tax Unpaid
3
5 Total Receipts (Add Lines 1 through 4)
Section B: Disbursements
From Schedule
Use Whole Gallons Only
1 Gallons Delivered Tax Collected and Gallons Blended or Dyed Fuel Used
5
2 Diversions (Special fuel only)
11
3 Taxable Gallons Sold or Used
4 Gallons Delivered Via Rail, Pipeline, or Vessel to Licensed Suppliers, Tax Not
Collected
6
5 Gallons Disbursed on Exchange for Other Suppliers or Permissive Suppliers
6X
6 Gallons Exported by License Holder
7
7 Gallons Sold to Unlicensed Exporters for Export
7A
8 Gallons Sold to Licensed Exporters for Export
7B
9 Gallons of Undyed Fuel Sold to the U.S. Government - Tax Exempt
8
10 Gallons Sold of Tax Exempt Dyed Fuel
10
11 Total Non-Taxable Disbursements (Add Lines 4 through 10)
(Information Only) Reporting of IVP Numbers Given By the Department
IVP Number
IVP Payment
IVP Number
IVP Payment
1.
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2.
8.
3.
9.
4.
10.
5.
11.
6.
12.
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