Form 105-19 - Exporters' Monthly Report

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Form 105-19

State of Oklahoma

Revised 11-2013

DST - 202

Oklahoma Tax Commission

Mail to:

(11/13)

Exporters’ Monthly Report

Oklahoma Tax Commission

2501 North Lincoln Boulevard

Oklahoma City, OK 73194

The report is due on the 27th of the next month.

Office Use Only

Exporter Name and Address

FEIN

Exporter Email Address

Period Covered

Undyed

Dyed

Undyed

Dyed

Blending

Aviation

Jet

Undyed

Dyed

Description

Schd

Gasoline

Diesel Fuel

Biodiesel

Material

Gasoline

Fuel

E85

Kerosene

Gallons exported - Oklahoma tax free

Gallons exported - Oklahoma tax-paid

Refund Calculation

Amount of gasoline tax refund due: (line 1 x $0.16)

Amount of E85 tax refund due: (line 1 x $0.16)

Amount of aviation gasoline tax refund due: (line 1 x $0.0008)

Amount of undyed diesel tax refund due: (line 1 x $0.13)

Amount of undyed biodiesel tax refund due: (line 1 x $0.13)

Amount of jet fuel tax refund due: (line 1 x $0.0008)

Amount of underground storage refund due: (line 1 x $0.01)

TOTAL REFUND DUE: (LINES 3 THRU LINES 9)

I/We declare under the penalties of perjury that this return including any accompanying schedules and statements has been examined by me/us and to the best of my/our knowledge and belief is a true, correct and

complete return made in good faith for the taxable period stated, pursuant to any existing laws requiring the filing of this return.

Name

Signature

Phone Number

Date

Audited by

Date

Approved by

Date

This form must be submitted in duplicate