Form L-3022 - Import/payment Voucher
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1
21350
STATE OF SOUTH CAROLINA
DEPARTMENT OF REVENUE
L-3022
(Rev. 7/8/11)
IMPORT/PAYMENT VOUCHER
4455
Mail To:
South Carolina Department of Revenue, Motor Fuel, Columbia, SC 29214-0133.
License Number
ONLY ONE IMPORT PER VOUCHER ALLOWED
Company Name:
FEIN
Address:
Import Verification Number:
Import Registration Date:
Period Covered
Manifest/Invoice 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
Total Gallons Imported
4.
Gasoline User Fee Due (Column A - Line 1 x $.16)
5.
Penalty
6.
7.
Interest
Total Gasoline User Fee, Penalty and Interest
8.
34-2301
Special Fuel User Fee Due (Col A - Line 2 + Col A - Line 3 x $.16)
9.
Penalty
10.
11.
Interest
12.
Total Special Fuel User Fee, Penalty and Interest
34-2101
13.
Inspection Fees Due (Line 4 x $.0025)
Penalty
14.
Interest
15.
16.
Total Inspection Fees Due, Penalty and Interest
34-2314
Environmental Impact Fees Due (Line 4 x $.0050)
17.
18.
Penalty
Interest
19.
20.
Total Environmental Impact Fees Due, Penalty and Interest
34-2312
Total Fees Paid with Voucher, Plus Penalty and Interest
(Add lines 8, 12, 16 and 20)
21.
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:
44551018
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