Form 105-Us - Oklahoma Petroleum Underground Tank Release Enviromental Cleanup Indemnity Fund

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105-US
Revised 12-2005
State of Oklahoma
Oklahoma Tax Commission
Oklahoma Petroleum Underground Tank Release
Enviromental Cleanup Indemnity Fund
Name of Licensee
FEI/SSN
For the Month of
Year
Address:
City/Town
State
ZIP
Telephone Number
Signature of Taxpayer
Total Receipts of Fuel:
Less Sales To:
Undyed
Dyed
Blending
Aviation
Jet
Undyed
Dyed
Undyed
Dyed
Biodiesel
Material
Gasoline
E85
Kerosene
Kerosene
Code
Description
Gasoline
Diesel Fuel
Diesel Fuel
Biodiesel
Fuel
01
State of Oklahoma
02
U.S. Government
03
Railroads
05
Exports
07
Agricultural Sales (only if applicable)
08
Cities and Counties (only if applicable)
09
School Districts (only if applicable)
10
Aircraft (only if applicable)
11
Diesel Off-Highway (only if applicable)
12
Tax Paid Fuel
Net Gallons ......
Total Gallons Subject to $0.01 Assessment
Assessment Due
$
10% Penalty (if paid after due date of report)
$
Less Credits (including refunds given to ultimate vendors)
$
Previous Billings or Credits Due per Attached Letter
$
Total Amount Due
(EFT Code 05203) MFL
$
Please Mail To: Oklahoma Tax Commission • 2501 North Lincoln Boulevard • Oklahoma City, OK 73194

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