Form Mf-90a - Motor Fuels Retailer'S Schedule Of Receipts

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KANSAS DEPARTMENT OF REVENUE
CUSTOMER RELATIONS
915 SW HARRISON ST.
TOPEKA, KANSAS 66625-8000
Phone Number: (785) 368-8222
FAX (785) 296-4993
MOTOR FUELS RETAILER'S SCHEDULE OF RECEIPTS
FACILITY #
COMPANY NAME
LICENSE NO.
FEIN NO.
TYPE OF SCHEDULE
MONTH & YEAR
PC-TYPE OF PRODUCT
167-LOW SULPHUR DIESEL #2 - CLEAR
Type of Schedule
65-GASOLINE
125-AVIATION GASOLINE
226-HIGH SULPHUR DIESEL - DYED
1. Gallons received tax paid
79-E85
130-JET FUEL
227-LOW SULPHUR DIESEL - DYED
2. Gallons received tax unpaid
124-GASOHOL
161-LOW SULPHUR DIESEL #1 - CLEAR
OTHER (see FTA Product Code list)
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
ACQUIRED FROM
NAME OF
CARRIER
NAME OR
SELLER'S
DATE
DOCUMENT
NET
GROSS
PRODUCT
CARRIER
FEIN
MODE
ORIGIN
DISTRIBUTOR LICENSE#
FEIN
RECEIVED
NUMBER
GALLONS
GALLONS
CODE
TOTAL
SEE INSTRUCTIONS ON REVERSE
MF-90A (Rev. 2/06)

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