Form Fr-400m - Motor Fuel Tax Return - 2012

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Government of the
FR-400M
*124000110002*
2012
MOTOR FUEL
District of Columbia
TAX RETURN
This is a FILL-IN format. Please do not handwrite
OFFICIAL USE ONLY
any data on this form other than your signature.
Vendor ID # 0002
Federal Employer Identification
Tax Period Ending (MMYY)
0112
Number (FEIN)
Fill in
if amended return.
Name of Importer
Fill in
if this is a final return.
Mailing address line 1
Phone number of person to contact
Mailing address line 2
City
State
Zip Code + 4
Gallons
Gallons
Distribution
Inventories
(all Fuels: Diesel & Gasoline)
(all Fuels: Diesel & Gasoline)
.
Sales and transfers out of DC (Schedule 10)
10
1. Opening inventory (including in transit)
2. Receipts at marketing locations in DC
11.
Sales to licensed importers in DC (Schedule 11)
from sources outside DC (Schedule 2)
12.
Sales to: (Schedule 12)
3. Receipts at marketing locations in DC
(a) US Government
(b) DC Government
from sources within DC (Schedule 3)
0
+
=
4. Direct delivery to other states
(Schedule 4)
.
13
Other non-taxable distributions (Schedule 13)
5. Direct delivery to customers in
DC (Schedule 5)
14.
Gain or loss. (If a gain, use minus sign to deduct)
6. Other receipts (Schedule 6)
0
15.
Total non-taxable distributions (add Lines 10 - 14)
0
7. Total (add Lines 1 - 6)
0
16.
Net Taxable Sales
8. Minus closing inventory (including in
transit)
.
17
Sales at self-operated retail service stations
0
9. To be accounted for (Line 7 minus
Line 8)
.
18
Taxable Use
0
.
19
Total taxable distribution (add Lines 16, 17 and 18)
.
0
20
Total of Lines 15 and 19 (must equal Line 9)
Tax Computation
Gallons
Dollars only
$
21.
0
0
Total taxable distribution of all Fuels: Diesel & Gasoline (from Line 19) X the set rate per gallon
00
22.
Total Taxable Sales and Use of Diesel Fuel (Schedule 22) gallons only.
$
0
00
23.
Minus tax paid on purchases (Schedules 2, 3, 4 and 5)
24.
Minus previously taxed sales to:
(a) US Government
(b) DC Government
(c) Diplomatic Corps Members
0
$
00
=
0
+
+
$
0
25.
Subtract total of Lines 23 and 24 from Line 21.
00
0
$
00
26.
Adjustment of previous month’s report (Schedule 26) Add or deduct.
Use minus sign to deduct
0
$
Tax Due (
Combine Lines 25 and 26. If a tax is due, enter the amount.)
27.
00
0
Will the funds for this payment come from an account outside the US?
Yes
No
See page .
$
Do not bracket the amount.
(Combine Lines 25 and 26. If there is an overpayment, enter the amount.)
Refund Due
00
28.
0
Will the refund you requested go to an account outside the US?
Yes
No
See page .
$
0
00
00
00
29.
Penalty $
and Interest $
due on the Line 27 amount
$
00
0
30.
Total amount due (add Lines 27 and 29)
Under penalties of law, I declare that I have examined this return and, to the best of my knowledge,
Preparer’s FEIN, SSN or PTIN
it is correct. Declaration of paid preparer is based on the information available to the preparer.
Preparer’s Phone Number
Officer’s signature
Title
Date
l
l
Paid preparer’s signature (If other than taxpayer)
Date
Revised 11/2011
2012 FR-400M
2012 FR-400M.indd 7
11/9/2011 11:42:29 AM

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