Form 80 - Nebraska Motor Fuels Carrier Report
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1
2Nebraska Motor Fuels Carrier Report
FORM
• Read instructions and complete schedule on reverse side
80
of this report, if applicable.
PLEASE DO NOT WRITE IN THIS SPACE
Federal Employer Identification Number
Reporting Month
Nebraska Identification Number
Check this box if you have no diverted loads of fuel.
Check this box to CANCEL.
Attach license and indicate cancellation date_________________________________________.
·
ROUND TO WHOLE GALLONS. Round down all amounts less than .50 and round up all amounts .50 through .99.
Total gross gallons of diverted loads of motor fuels from Motor Fuels Diversion Schedule . . . . . . . . . . .
All diverted loads of fuel reported on this form must also be registered with the Fueltrac Diversion
Registration System. Failure to timely register these loads will result in administrative penalties being
imposed at the rate of $1,000 per violation.
Likewise, all diverted loads of fuel registered with the Fueltrac Diversion Registration System must also
be reported on this form.
Under penalties of law, I declare that I have examined this report and schedule(s), and to the best of my knowledge and belief, they are correct and complete.
sign
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Authorized Signature
Telephone Number
Signature of Preparer Other than Taxpayer
Telephone Number
Title
Date
Address
Date
INSTRUCTIONS
WHO MUST FILE. Every common or contract carrier transporting
WHEN TO FILE. This report, properly signed, is considered timely
motor vehicle fuels, aircraft fuels, or diesel fuels in Nebraska is
filed if transmitted or postmarked on or before the 25th day of
required to file a Nebraska Motor Fuels Carrier Report, Form 80.
the month following the month covered by this report. A report is
required even if no fuel was transported in a common or contract
Electronic filing of reports is highly encouraged and is available
carriage capacity by you during the reporting month.
through our Web site. If filing by paper, file only the original,
PENALTY. A penalty of $50 will be imposed on late reports filed
preidentified report issued by the Motor Fuels Division. If the name
within 10 days after the due date. An additional penalty of $100 will
and address is incorrect, mark through the erroneous information
be imposed on reports filed more than 10 days after the due date.
and plainly print the correct information.
RECORDS. The records required to substantiate this report must
A report is required for each month or fraction of a month during
be retained and available for at least three years, or five years if the
which the license is active whether or not any motor vehicle fuels,
required reports are not filed. Please make copies of this report and
aircraft fuels, or diesel fuel were diverted from or to Nebraska.
schedules for your records.
SIGNATURE. This report must be signed by the owner, partner, or
A diverted load occurs whenever the bill of lading indicates
corporate officer. If the taxpayer authorizes another person to sign
a destination state other than the state to which the fuel was
this report, a power of attorney must be on file with the Motor Fuels
delivered.
Division. Any person paid for preparing a taxpayer’s report must
If there were no diverted loads for the reporting period, check the
sign the report as preparer.
box under the Federal Employer Identification Number, sign the
TAXPAYER ASSISTANCE. For additional information, please
report, and mail by the due date.
contact the Motor Fuels Division, P. O. Box 98904, Lincoln, NE
68509-8904 or call toll free 800-554-FUEL (800-554-3835). Lincoln
If you had any diverted loads for the reporting period, complete the
area residents call 471-5730.
Motor Fuels Diversion Schedule on the reverse.
THIS REPORT IS DUE ON OR BEFORE THE 25TH DAY OF THE MONTH FOLLOWING THE REPORTING MONTH INDICATED ABOVE.
Mail the original report and schedule(s) to: MOTOR FUELS DIVISION, P.O. BOX 98904, LINCOLN, NE 68509-8904
10-2009
3-332-1994 Rev.
Supersedes 3-332-1994 Rev. 10-2008
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