R-5397 (7/06) Batch Type 533 or 534
If your name has
If your address has
If amended return,
If final return,
O
O
O
O
changed, mark circle.
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Account Number
SUPPLIER/PERMISSIVE
SUPPLIER MONTHLY RETURN
Name(1)
Mail to:
Address(1)
Louisiana Department of Revenue
P. O. Box 201
Address(2)
Baton Rouge, LA 70821-0201
(225) 219-7656 (225) 219-2114 (TDD)
City
State ZIP
FOR OFFICE USE ONLY.
Field flag
SP
Filing
Period_____________________
FEIN__________________________
MM/YY
Summary
C
D
E
A
B
Undyed
Dyed
Aviation
(Complete Page 2,
Gasohol
Gasoline
Diesel Fuels
Diesel Fuels
Fuels
Lines 15 through 41 first.)
Taxable gallons
1
(From Page 2, Line 38)
Tax
2
(Multiply Line 1 by $.20.)
00
00
00
00
00
Less: Discount of 1.5% of Line 2
3
00
00
00
00
00
Net tax due
4
(Subtract Line 3 from Line 2.)
00
00
00
00
00
Credit for tax on reported
5
bad debt (Sch. F – R-5404)
00
00
00
00
00
Repayment of previous
6
bad debt (Sch. F – R-5404)
00
00
00
00
00
Total tax due (Subtract Line 5
7
from Line 4 and add Line 6.)
00
00
00
00
00
Gallons subject to inspection fee
8
(From Page 2, Line 41)
Inspection fee due
9
(Multiply Line 8 by $.00125.)
00
00
00
00
00
Total Tax and Fee Due
10
(Add Line 7 and Line 9.)
00
00
00
00
00
$
11
Total (Add Columns A through Column E, Line 10.)
11
00
$
12
Penalty (See instructions.)
12
00
$
13
Interest (See instructions.)
13
00
Total Amount Due (Enter the total of Lines 11, 12, and 13.)
14
14
$
PAY THIS AMOUNT.
Make payment to: Louisiana Department of Revenue.
Do not send cash.
00
This return and payment are due on or before the 22nd 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
Name of purchaser
7641