Form 86-002 - Retailers E85 Quarterly Report
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Retailers E85 Quarterly Report
Iowa Department of Revenue
86-002a (08/24/11)
Quarter Ending: ________________________________
Due Date: _____________________________________
Mailing Address
Location Address
Name: ________________________________________
Name: ________________________________________
Address 1: _____________________________________
Address 1: _____________________________________
Address 2: _____________________________________
Address 2: _____________________________________
City: __________________________________________
City: __________________________________________
State: _________________ Zip Code: _______________
State: _________________ Zip Code: _______________
County Name: __________________________________
Social Security Number: __________________________
Federal Employer ID No.: _________________________
Iowa Sales Tax Permit No.: _______________________
Iowa Weights & Measures No.: ____________________
QUARTERLY REPORT
1. Retail Total Gross Gallons of E85
sold for the quarter:............................... 1. ____________________
Report E70 and E85 as E85.
2. Total Gross Gallons Purchased
for the quarter: ...................................... 2. ____________________
Complete schedule 86-003.
If first time filing, start date for selling E85: ______________________
Please check which of the following apply to your E85 Total:
Non Blender, E85 purchased as a blended product
E85 product Blender of E85 at this retail location
Other, please explain: _________________________________
_____________________________________________________
_____________________________________________________
Mail To:
Questions?
Iowa Department of Revenue
Call: 515/281-6447
Compliance Division
Fax: 515/281-3756
Motor Fuel Unit
E-mail: idrmotorfuel@iowa.gov
PO Box 10456
Des Moines, IA 50306-0456
I, the undersigned, declare under penalty of perjury that I have examined this report, including all
accompanying documentation, and to the best of my knowledge and belief, it is a true accurate and complete
statement.
Signature: ________________________________ Date: ____________ Phone Number: _____________________
Print Name: _______________________________ Title: ____________ E-mail Address: _____________________
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