Form R-5404 - Schedule F - Supplier/permissive Supplier - Schedule For Tax Bad Debt Credit/repayment

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R-5404 (7/06)
Page __________ of ___________
Schedule F
Supplier/Permissive Supplier – Schedule for
Tax Bad Debt Credit/Repayment
Company Name
LA Revenue Account Number
Date
Filing Period
Address
Telephone Number
City
State
ZIP
Fax Number
Product Type
065 – Gasoline 123 - Alcohol
124 – Gasohol
160 – Clear Diesel
142 – Clear Kerosene
170 – Clear Biodiesel Other ________________________________________
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
Licensed Distributor/Importer
Product
Document
Net Taxable
Amount of
Amount of
Period When
Date
Name
Rev. ID
Purchased
Type
Number
Gallons
Credit Claimed
Credit Repaid
Credit Claimed
Total Amount of Credit Claimed/Repaid

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