Form Mf-219 - Motor Fuel Inventory Tax Return For Fuels Owned July 1, 2003

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KANSAS DEPARTMENT OF REVENUE
CUSTOMER RELATIONS
MOTOR FUEL INVENTORY TAX RETURN
FOR FUELS OWNED JULY 1, 2003
Please check each box that applies:
Licensed Motor Vehicle Fuel and Special Fuel
Distributor
Licensed Motor Vehicle Fuel and Special Fuel
Importer/Exporter
Licensed Motor Fuel Retailer
* SEE INSTRUCTIONS ON REVERSE SIDE FOR COMPLETING RETURN.
NUMBER OF GALS
TAX DUE AT
PENALTY
TOTAL TAX, PENALTY
FUEL TYPE
IN INVENTORY 7/1/03
$.01 PER GAL
& INTEREST
& INTEREST DUE
1. Gasoline
2. Gasohol
3. Clear Diesel
4. Total Amount Due
MAKE REMITTANCE PAYABLE TO KANSAS DEPARTMENT OF REVENUE
Please indicate below all license numbers and locations for which the above inventory tax is remitted:
License #
Facility # Gals Gasoline Gals Gasohol Gals Diesel
Street Address
City
Signature
Title
Date
Telephone Number
MF-219 (Rev. 5/03)

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