Fillable Form R-5398 - Distributor/exporter/ Blender Monthly Return printable pdf download

Form R-5398 - Distributor/exporter/ Blender Monthly Return

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TAXPAYER ACCOUNT ID

TAXPAYER NAME

ADDRESS 1

ADDRESS 2

CITY STATE ZIP

R-5398 (12/07) Batch Types 523 or 524

If your name has

If your address has

If amended return,

If final return,

changed, mark circle.

mark circle.

Taxpayer Account ID:

DISTRIBUTOR/EXPORTER/

BLENDER MONTHLY RETURN

Mail to:

Taxpayer Name:

Louisiana Department of Revenue

Address 1:

P. O. Box 201

Baton Rouge, LA 70821-0201

Address 2:

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

City, State, ZIP:

F i e l d f l a g

FOR OFFICE USE ONLY.

Filing

DEB

Period_____________________

FEIN__________________________

MM/YY

Tax Computation

Undyed

Dyed

Aviation

(Complete Page 2, Lines 14

Gasoline

Diesel Fuels

Fuels

Gasohol

through 35 first.)

Gross taxable gallons (Add Page 2,

Lines 18(A)(B)(C), 19, 21, 22, 29 and 34.)

Taxed gallons not subject to the tax

(Add Page 2, Lines 23 (A)(B), 25 and

27 (A)(B)(C).)

Net taxable gallons

(Subtract Line 2 from Line 1.)

Tax due

(Multiply Line 3 by $.20.)

Gallons subject to inspection fee

(Add Page 2, Lines 18, 19, 29 and 35.)

Fee-paid gallons not subject to fee

(Add Page 2, Lines 25, 26, 27 and 28.)

Net gallons subject to fee

(Subtract Line 6 from Line 5.)

Inspection fee due

(Multiply Line 7 by $.00125.)

Total Tax and Fee Due

(Add Line 4 and Line 8.)

Total (Add Line 9, Columns A through Column E.)

Penalty (See instructions.)

Interest (See instructions.)

Total Amount Due (Enter the total of Lines 10, 11, and 12.)

PAY THIS AMOUNT. 13 $

Make payment to: Louisiana Department of Revenue.

Do not send cash.

This return and payment are due on or before the 20th day of the month following the period covered. If the due date falls on a weekend or legal holiday,

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 the return is prepared by a person other than the taxpayer, his declaration is based on all the information relating to the matters required to be

reported of which he has any 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