Form 82-053 - Retailers Motor Fuel Gallons Annual Report

Iowa Department of Revenue

Retailers Motor Fuel Gallons Annual Report

SIGNATURE REQUIRED

Period: Jan. 1, 2011, through Dec. 31, 2011

I, the undersigned, declare under penalty of perjury that

January 31, 2012.

Due Date:

I have examined this report, including all accompanying

Iowa License No: _____________________________

documentation, and to the best of my knowledge and

belief, it is a true, accurate and complete statement.

Name: ______________________________________

Signature: __________________________________

Address 1: ___________________________________

Date: ______________________________________

Address 2: ___________________________________

Print Name: _________________________________

City: ________________________________________

Title: ______________________________________

State: _____________________ Zip Code: ________

Phone Number: ______________________________

County Name: ________________________________

E-mail Address: ______________________________

Social Security Number: ________________________

Mail To: Iowa Department of Revenue

Federal Employer ID Number: ___________________

PO Box 10471, Des Moines, Iowa 50306-0471

Questions? Call 515/281-3114 or 1-800-367-3388

Iowa Sales Tax Permit No: ______________________

E-mail idr@iowa.gov

(for this location)

Round to the nearest whole gallon.

File a separate report for each retail location.



If you do not sell motor fuel at retail, please return the

Report gross gallons for each type of fuel sold for final



form with zeros in the gallons column.

consumption.

Complete for all types of fuel sold:

Type of Fuel

Gross Gallons

(round to the nearest whole gallon)

Gasoline (non-ethanol) Gallons ................................................. 1. _____________________________ 

Gasoline Blend (10% - 14% ethanol = E10) .............................. 2. _____________________________ 

Gasoline Blend (15% - 69% ethanol = E15/E20) ....................... 3. _____________________________ 

Gasoline Blend (70% - 85% ethanol = E85) .............................. 4. _____________________________ 

Diesel Gallons (including biodiesel)

Diesel (clear) Gallons ............................................................. 5. _____________________________ 

Diesel (dyed) Gallons ............................................................. 6. _____________________________ 

Total Gross Gallons For All Fuel Types

(add lines 1 thru 6) ..................................................................... 7. _____________________________ 

Diesel Blend (Biodiesel) Sales

All locations must complete this section and report diesel blends (2% to 99.8% biodiesel). If you do not sell biodiesel at

retail, please return the form with zeros in the gallons column on lines 8, 9, 10.

Type of Diesel Blend (Biodiesel )

Gross Gallons

(round to the nearest whole gallon)

Clear B2 ................................... 8a ____________________ 

Clear B5 ................................... 8b ____________________ 

Clear B10 ................................. 8c ____________________ 

Clear B20 ................................. 8d ____________________ 

Clear B_____ ............................ 8e ____________________ 

Clear Diesel Blend (Biodiesel) Subtotal

(add lines 8a thru 8e). ............................................................. 8. _____________________________ 

Dyed B2 ................................... 9a ____________________ 

Dyed B5 ................................... 9b ____________________ 

Dyed B10 ................................. 9c ____________________ 

Dyed B20 ................................. 9d ____________________ 

Dyed B_____ ........................... 9e ____________________ 

Dyed Diesel Blend (Biodiesel) Subtotal

(add lines 9a thru 9e) .............................................................. 9. _____________________________ 

Total Diesel Blend (Biodiesel) Gallons Sold

(add lines 8 and 9) ................................................................... 10. _____________________________ 

82-053a (09/27/11)

Form 82-053 - Retailers Motor Fuel Gallons Annual Report - 2011

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