Form L-2115 - Fuel Blender Return
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STATE OF SOUTH CAROLINA
DEPARTMENT OF REVENUE
L-2115
FUEL BLENDER RETURN
(Rev. 7/7/11)
4203
Mail to: South Carolina Department of Revenue, Motor Fuel, Columbia, SC 29214-0132.
Phone Number: (803) 896-1990
License Number
COMPANY NAME AND ADDRESS
FEIN
Period Covered
THIS RETURN IS DUE ON OR BEFORE THE LAST DAY OF THE FOLLOWING MONTH
1.
Total Gallons of Fuel Grade Ethanol Blended with Gasoline
2.
Total Gallons of Undyed Kerosene Blended with Undyed Diesel
3.
Total Gallons of Other Product Blended with Undyed Diesel
4.
Total Gallons of Product Blended with Dyed Diesel
5.
Gasoline User Fee Due (Multiply Line 1 by $.16)
6.
Penalty
7.
Interest
8.
Total Gasoline User Fee Due on Gallons Blended
34-2301
9.
Diesel User Fee Due (Add Lines 2 and 3 then Multiply by $.16)
10.
Penalty
11.
Interest
12.
Total Diesel User Fee Due on Gallons Blended
34-2101
13.
Inspection Fees Due (Add Lines 1, 3, and 4 then Multiply by $.0025)
14.
Penalty
15.
Interest
16.
Total Inspection Fees Due on Gallons Blended
34-2314
17.
Environmental Fees Due (Add Lines 1, 3, and 4 then Multiply by $.0050)
18.
Penalty
19.
Interest
20.
Total Environmental Fees Due on Gallons Blended
34-2312
Total Fees Due, Plus Penalty and Interest
21.
(Line 8 + Line 12 + Line 16 + Line 20)
I hereby certify that the information contained in this return (including all attachments) has been examined by
me and to the best of my knowledge, is true, correct and a complete return.
Name:
Signature:
Date:
Phone:
42031039
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