Form R-5434 - Notification Of Loss Of Motor Fuel - 2006
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R-5434 (7/06)
Notification of Loss of Motor Fuel
Mail to:
Office Audit Division
P. O. Box 66362
Baton Rouge, LA 70896-6362
(225) 219-2270 (225) 219-2114 (TDD)
(225) 219-2267 (Fax)
See instructions on reverse side – round to whole gallons.
Company’s name
LA Revenue Account Number
FEIN/SSN
TCN
Month/Year
Location Address
City
State
ZIP
Telephone Number
Mailing Address
City
State
ZIP
Fax Number
Exact Location of Loss – If loss occurred while in transit or at time of unloading, give invoice or manifest number
below and attach copy to this claim.
CAUSE OF LOSS
PRODUCT CODE
065 – Gasoline
142 – Clear Kerosene
072 – Dyed Kerosene
123 – Alcohol
160 – Clear Diesel Fuel
228 – Dyed Diesel Fuel
124 – Gasohol
284 – Bio-Diesel
Other _________________
125 – Aviation Gasoline
130 – Jet Fuel
Date of
Manifest
Gallons Listed
Owner of Fuel
Product
Number of Net
Date of Loss
Manifest
Number
on Manifest
Company, City, State
Code
Gallons Lost
TOTAL GALLONS LOST
Under the penalties of perjury, I declare that I have examined this notification, including all accompanying documents, and to the best of my knowledge
and belief, it is true, correct, and complete.
Signature of Company Official
Date
Telephone number
Print Name
Title
Department Use Only
Approved by:
Date Approved:
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Parent category: Financial