Form R-5346 - Motor Fuel Transporter Monthly Report

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R-5346 (7/06) Batch Type 593 or 594
If your name has
If your address has
If amended return,
If final return,
O
O
O
O
changed, mark circle.
changed, mark circle.
mark circle.
mark circle.
Account Number
Motor Fuel Transporter
Monthly Report
Name(1)
Mail to:
Address(1)
Louisiana Department of Revenue
P. O. Box 201
Address(2)
Baton Rouge, LA 70821-0201
(225) 219-7656 (225) 219-2114 (TDD)
City
State
ZIP
FOR OFFICE USE ONLY.
Field flag
Filing
Period_____________________
FEIN__________________________
MM/YY
FT
Transactions for
A
B
C
D
E
Gasohol
Gasolines
Undyed Diesel Fuels
Dyed Diesel Fuels
Aviation Fuels
the Month
Gallons transported into LA
1
(Sch. G – R-5348)
Gallons transported out of LA
2
(Sch. G – R-5348)
Gallons transported intrastate
3
(Sch. G – R-5348)
Total gallons transported
4
(Add Lines 1, 2, and 3.)
Penalty Amount Due (If not filed within 30 days from due date, penalty of $100 is due.)
5
5 $
PAY THIS AMOUNT.
Make payment to: Louisiana Department of Revenue
Do not send cash.
00
This return is due on or before the 20
th
day of the month following the period covered. If the due date falls on a weekend or legal holi-
day, the return is due the next business day.
Under the penalties of perjury, I declare that I have examined this return, including all accompanying documents, and to the best of my knowledge and
belief, it is true, correct, and complete. If a person other than the taxpayer prepares the return, this declaration is based on all the information relating
to the matters required to be reported of which the preparer has knowledge.
Date
Signature
Title
Telephone Number
Date
Signature of preparer other than taxpayer
Preparer ID
Telephone Number
Complete only if change in business status has occurred. Please print or type.
Date business discontinued
Date business sold
Name of purchaser
7603

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