Form L-2109 - Diversion / Payment Voucher
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STATE OF SOUTH CAROLINA
DEPARTMENT OF REVENUE
L-2109
DIVERSION / PAYMENT VOUCHER
(Rev. 7/21/11)
Mail To:
South Carolina Department of Revenue,
4197
Motor Fuel, Columbia, SC 29214-0133
License Number
ONLY ONE DIVERSION PER VOUCHER ALLOWED
Company Name:
FEIN
Address:
Diversion Number:
Diversion Registration Date:
Period Covered
Bill Of Lading Number:
Column A Subject
Column B Not Subject
to User Fee Gallons
to User Fee Gallons
1.
Gallons of Gasoline
2.
Gallons of Diesel Fuel
3.
Gallons of all other Motor Fuel Product
4.
Total Gallons Diverted
5.
Gasoline User Fee Due (Column A Line 1 x $.16)
6. Penalty
7.
Interest
8.
Total Gasoline User Fee, Penalty and Interest
34-2301
9.
Special Fuel User Fee Due (Col A Line 2 + Col A Line 3 x $.16)
10.
Penalty
11.
Interest
12.
Total Special Fuel User Fee, Penalty and Interest
34-2101
13.
Inspection Fees Due (Line 4 x $.0025)
14.
Penalty
15.
Interest
16.
Total Inspection Fees Due, Penalty and Interest
34-2314
17.
Environmental Impact Fees Due (Line 4 x $.0050)
18.
Penalty
19.
Interest
20.
Total Environmental Impact Fees Due, Penalty and Interest
34-2312
Total Fees Paid with Voucher, Plus Penalty and Interest
21.
(Add lines 8, 12, 16 and 20)
If you have any questions or need assistance calculating penalty and interest, please contact this office at (803) 896-1990.
I hereby certify that the information contained in this voucher has been examined by me and to the best of my knowledge, is
true and correct.
Name:
Signature:
Phone:
Date:
41971029
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