Form L-2123 - Miscellaneous Motor Fuel Monthly Return
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1
2STATE OF SOUTH CAROLINA
1350
1350
DEPARTMENT OF REVENUE
L-2123
MISCELLANEOUS MOTOR FUEL MONTHLY RETURN
(Rev. 12/13/13)
4211
Mail to: SC Department of Revenue, Motor Fuel, Columbia, SC 29214-0132
The return is due on the 22nd of the next month.
License Number
LICENSEE NAME AND ADDRESS
FEIN
Period Covered
FED EXEMPT
DESCRIPTION
SCHD
DYED DIESEL
KEROSENE
LP GAS
CNG/LNG
OTHER
1
GALLONS SOLD FOR USE
IN HIGHWAY VEHICLES
2
GALLONS USED IN
HIGHWAY VEHICLES
3
TOTAL GALLONS SUBJECT TO
THE MOTOR FUEL USER FEE
CALC
4
TOTAL GALLONS SUBJECT TO
THE OTHER APPLICABLE FEES
SPECIAL FUELS USER FEE DUE
5
ADD LINE 3 FOR ALL COLUMNS, MULTIPLY BY $.16
6
PENALTY
7
INTEREST
8
TOTAL SPECIAL FUELS USER FEE DUE
34-2101
INSPECTION FEES DUE
ADD LINE 4 FOR CNG/LNG AND OTHER COLUMNS, MULTIPLY BY $.0025
9
10
PENALTY
11
INTEREST
12
TOTAL INSPECTION FEES DUE
34-2314
ENVIRONMENTAL IMPACT FEES DUE
ADD LINE 4 FOR CNG/LNG AND OTHER COLUMNS, MULTIPLY BY $.0050
13
14
PENALTY
15
INTEREST
16
TOTAL ENVIRONMENTAL IMPACT FEES DUE
34-2312
17
TOTAL FEES DUE, PLUS PENALTY AND INTEREST
(Line 8 + Line 12 + Line 16)
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:
(Print)
Phone:
Date:
Audited By:
Audit Date:
42111021
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