Form R-5292 - Schedule E - Schedule Of Exportations To Support Deduction Claimed
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1R-5292 (07/06)
Page ________ of _________
Schedule E
Schedule of Exportations to Support
Deduction Claimed
To be prepared in duplicate and forwarded to motor fuel taxing authority in the state into which the motor fuel was delivered for certification. A signed
document must accompany return on which deduction is claimed.
Company Name
LA Revenue Account Number
Product Type
Filing Period
Address
City
State
ZIP
Mode of Transport
Product Type (Only one product type per page)
B = Barge
PL= Pipeline
065 - Gasoline
125 - Aviation Gasoline
072 - Dyed Kerosene
170 - Clear biodiesel
J = Truck
ST = Stationary Transfer
123 - Alcohol
130 - Jet Fuel
160 - Clear Diesel
171 - Dyed biodiesel
R = Rail
BA = Book Adjustment
124 - Gasohol
142 - clear Kerosene
228 - Dyed diesel
Other __________________
S = Ship
(1)
(2)
(3)
(4)
(5)
(6)
Date
Document Number
Transporter
Mode
Destination (city, state)
Net Gallons
Total
Receipt of applicable taxes and fees on the above motor fuel imported into the state of _____________________________________ is hereby acknowledged.
Note to Tax Official:
Please sign both copies and
____________________________________________________________
forward to the company named above.
Signature and Title of State Official
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