Form R-5376 - Schedule A - Interstate Motor Fuel User Quarterly Tax Return Detail Of Miles Traveled And Diesel Fuels Consumed Page 2

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R-5376 (7/06)
Interstate Motor Fuel User
Quarterly Tax Return
Schedule B
Louisiana Purchases of
Taxpaid Diesel Fuels
Company Name
FEIN
LA Revenue Account Number
Filing Period
Section 1 Bulk Purchases From Distributors
(attach copies of invoices)
Date
Invoice Number
Purchased From
Address
Gallons
Total – enter here and on Line (b) of Section 3 below
Section 2 Service Station Purchases
(attach original invoices if applying for refund)
Date
Invoice Number
Purchased From
Address
Gallons
Total – enter here and add to Line (d), Section 3 below
Section 3 Louisiana Taxpaid Storage
a. Beginning Inventory (closing inventory from previous quarter)
b. Bulk purchases (total from Section 1)
c. Closing inventory
d. Total gallons of fuel withdrawn from storage (Line a plus Line b minus Line c)
Section 4. Total Gallons Placed in Vehicles in Louisiana
Section 2 total plus Line d, Section 3. Enter here and on Line 6 of return, R-5375
7676

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