Form R-5376 - Schedule A - Interstate Motor Fuel User Quarterly Tax Return Detail Of Miles Traveled And Diesel Fuels Consumed

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R-5376 (7/06)
Interstate Motor Fuel User
Quarterly Tax Return
Schedule A
Detail of Miles Traveled and
Diesel Fuels Consumed
Company Name
FEIN
LA Revenue Account Number
Filing Period
NOTE: To be completed and submitted with Interstate Motor Fuel User Quarterly Tax Return. See instructions on reverse side of the return form R-5375.
Column 1
Column 2
Column 3
Column 4
Name of State
Miles Traveled
Gallons Consumed
Gallons Put in Vehicles
Louisiana
OTHER STATES
(list by state)
Total Operations in All States
7675

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