Fillable Form R-5410 - Fuel Floor Stock Tax Return printable pdf download

Form R-5410 - Fuel Floor Stock Tax Return

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TAXPAYER ACCOUNT ID

TAXPAYER NAME

ADDRESS 1

ADDRESS 2

CITY STATE ZIP

R-5410 (7/06) Batch Type 983 or 984

If your name has

If your address has

If amended return,

If final return,

changed, mark circle.

mark circle.

Account Number

FUEL FLOOR STOCK TAX RETURN

Name(1)

Mail to:

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

ZIP

State

FOR OFFICE USE ONLY.

Field flag

Please mark if

❏

Filing

No inventory as of July 1, 2006.

❏

07/06

Period_____________________

FEIN__________________________

All inventories are tax and/or fee paid.

MM/YY

DUE DATE: This report must be filed on or before August 1, 2006. Failure to file this return timely will be

subject to a $100 penalty. The amount of tax due must be fully paid by January 1, 2007, or

applicable penalty and interest will apply.

Summary

Gasoline/

Undyed Diesel Fuels/

Dyed Diesel Fuels/

Aviation

Gasohol

Kerosene

Fuels

Gallons in storage as of close of

business on June 30, 2006, on

which tax has not been paid

Tax due

(Multiply Line 1 by $.20.)

Gallons in storage as of close of

business on June 30, 2006, on

which inspection fee has not

been paid.

Inspection fee due (Multiply Line

3 by $.00125.)

Total Tax and Fee due

(Add Line 2 and Line 4.)

Total (Add Line 5, Columns A, B, C, and D.)

Late filing penalty (See instructions.)

Late payment penalty (See instructions.)

Interest (See instructions.)

Total Amount Due (See instructions.)

PAY THIS AMOUNT. 10 $

Make payment to: Louisiana Department of Revenue.

Do not send cash.

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

7667