Fillable Form R-5411 - Fuel Backup Tax Return printable pdf download

Form R-5411 - Fuel Backup Tax Return

Download a blank fillable Form R-5411 - Fuel Backup Tax Return in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form R-5411 - Fuel Backup Tax Return with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

R-5411 (7/06) Batch Type 973 or 974

If your name has

If your address has

If amended return,

If final return,

changed, mark circle.

mark circle.

Account Number

FUEL BACKUP 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

State

ZIP

Field flag

FOR OFFICE USE ONLY.

Filing

Period____________________________

MM/YY

Undyed

Dyed

Aviation

Tax Computation

Gasohol

Gasoline

Diesel Fuels

Fuels

Non-taxed fuel that was

sold or consumed for

FOR OFFICE USE ONLY.

Field flag

taxable purposes

Taxable fuel used for

taxable purposes on which

an exemption or refund was

allowed

Total gallons subject to tax

(Add Line 1 and Line 2.)

Tax due

(Multiply Line 3 by $.20.)

Gallons of fuel used for tax-

able purposes on which the

inspection fee was not paid

Inspection fee

(Multiply Line 5 by .00125.)

Total Tax and Fee Due

(Add Line 4 and Line 6.)

Total (Add amounts in Columns A through E, Line 7.)

Penalty (See instructions.)

Interest (See instructions.)

Total Amount Due (Enter the total of Lines 8, 9, and 10.)

PAY THIS AMOUNT.

Make payment to: Louisiana Department of Revenue.

Do not send cash.

This return and payment are 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 and payment are due the next business day. No return is required to be filed if there is no reportable activity.

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

7669