Form R-5401 - Schedule C - Motor Fuel Tax Multiple Schedule Of Terminal Rack Removals

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R-5401 (7/06)
Page_____ of _____
Schedule C
Motor Fuel Tax Multiple Schedule of Terminal Rack Removals
only)
(to be used by Suppliers/Permissive Suppliers
Company Name
LA Revenue Account Number
Type of Schedule
Product Type
Filing Period
Type of Schedule
Mode of Transport
Product Type (Only one product type per page)
14 Gallons removed for direct sale to US government
B = Barge
065 – Gasoline
130 – Jet Fuel
228 – Dyed Diesel
15 Gallons removed for unlicensed customers
J = Truck
123 – Alcohol
072 – Dyed Kerosene
170 – Clear Biodiesel
16 Gallons removed for Louisiana licensees
R = Rail
124 – Gasohol
142 – Clear Kerosene
171 – Dyed Biodiesel
17 Gallons exported destination tax collected
S = Ship
125 – Aviation Gasoline 160 – Clear Diesel
Other ________________
18 Gallons sold within bulk transfer/terminal system tax and/or fee
PL = Pipeline
collected from unlicensed customer
ST = Stationary Transfer
19 Gallons removed for own use
BA = Book Adjustment
20 Gallons of dyed diesel fuels removed for use in seagoing vessels
(1)
(2)
(3)
(4)
(5)
(6)
(7)
Purchaser
City, State of
Doc.
Net
Name
Rev. ID
Origin
Destination
Date
Mode
Carrier Name
Number
Gallons
Total

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