Fillable Form R-5375 - Interstate Motor Fuels User Quarterly Tax Return printable pdf download

Form R-5375 - Interstate Motor Fuels User Quarterly Tax Return

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R-5375 (7/06)

If your name has

If your address has

If amended return,

If final return,

changed, mark circle.

mark circle.

INTERSTATE MOTOR FUELS USER

QUARTERLY TAX RETURN

Mail to:

Louisiana Department of Revenue

P. O. Box 201

Baton Rouge, LA 70821-0201

(225) 219-7656 (225) 219-2114 (TDD)

FOR OFFICE USE ONLY.

F i e l d f l a g

IMU

Filing

Period_____________________

MM/YY

❏

Round to nearest

Type of fuel used:

Diesel

LPG

Other

Gallon/Dollar

1 Total miles traveled in all states (Schedule A, Total from Column 2)

2 Total gallons of fuel consumed in all states (Schedule A, Total from Column 3)

3 Average miles per gallon (Divide Line 1 by Line 2 and round to 2 decimal places.)

4 Miles traveled in Louisiana (Schedule A, Column 2, “Louisiana” line)

5 Fuel used in Louisiana (Divide Line 4 by Line 3.)

6 Fuel placed in vehicles in Louisiana (Schedule B, Section 4)

7 Taxable gallons (If Line 5 is greater than Line 6, enter the difference)

8 Credit gallons *(If Line 6 is greater than Line 5, enter the difference)

9 Tax due *(Multiply Line 7 by $.20.)

10 Penalty (See instructions.)

11 Interest (See instructions.)

Total amount due (Add Lines 9, 10, and 11.)

Pay this amount.

Make payment to: Louisiana Department of Revenue

Do not send cash.

*No refund will be made for less than $3.00.

This return is due on or before the 25th day of the month following the period covered and becomes delinquent the first day thereafter. If the due date falls

on a legal holiday or weekend, the return is due the next business day after the due date.

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

Complete only if change in business status has occurred. Please print or type.

Date business discontinued

Date business sold

Name of purchaser

7673