Fillable Form R-5393 - Terminal Operator Monthly Return printable pdf download

Form R-5393 - Terminal Operator Monthly Return

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R-5393 (7/06)

Batch Types 563 or 564

If your name has

If your address has

If amended return,

If final return,

changed, mark circle.

mark circle.

Account Number

TERMINAL OPERATOR

Name(1)

MONTHLY RETURN

Mail to:

Address(1)

Louisiana Department of Revenue

Address(2)

P. O. Box 201

Baton Rouge, LA 70821-0201

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

City

State

ZIP

FOR OFFICE USE ONLY.

Field flag

Filing

TOM

Period_____________________

FEIN__________________________

TCN_____________________

MM/YY

Transactions

Undyed

Dyed

Aviation

for the Month

Gasohol

Gasoline

Diesel Fuels

Fuels

Actual beginning inventory

(Sch. H – R-5394)

Total receipts

(Sch. I – R-5395)

Total gallons available

(Add Lines 1 and 2.)

Losses reported during

period (Attach copies of

notifications.)

Total disbursements

(Sch. J – R-5396)

Computed ending

inventory (Subtract

Lines 4 and 5 from Line 3.)

Actual Ending inventory

(Sch. H – R-5394)

Stock gain

(See instructions.)

Stock loss

(See instructions.)

Penalty Amount Due (If not filed within 30 days from due date, penalty of $100 is due.)

10 $

PAY THIS AMOUNT.

Make payment to: Louisiana Department of Revenue.

Do not send cash.

This return is 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