Form Rev-1096b Mf - Liquid Fuels And Fuels Tax Report Receipts And Disbursements Summary - 2013

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Liquid Fuels and Fuels Tax Report
Receipts and Disbursements Summary
BUREAU OF MOTOR &
ALTERNATIVE FUEL TAXES
(SEE INSTRUCTIONS ON REVERSE SIDE)
PO BOX 280646
HARRISBURG PA 17128-0646
TELEPHONE 1-800-482-4382
REV-1096B MF (01-13)
DISTRIBUTOR’S NAME:
FEIN:
TAX PERIOD:
Section I. - Receipts:
Item
From
Gasoline
Diesel, Biodiesel
Jet Fuel
Aviation
Schedule
and
and
Gas
Gasohol
Kerosene
1.
PA Refinery Production
XXXXXXX
2.
Gallons Received PA Tax Paid and
Placed in Inventory
1
3.
Gallons Received PA Tax Paid and
Direct Shipped to Customers
1F
4.
Gallons Received Tax Free
(From other PA registered distributors)
2
5.
Gallons Received Tax Free and
Direct Shipped to Customers
2F
6.
Gallons Imported & Direct Shipped
to PA Customers
3
7.
Gallons Imported into
Storage in PA
4
8.
Total Receipts
XXXXXXX
Section II. - Disbursements:
Item
From
Gasoline
Diesel, Biodiesel
Jet Fuel
Aviation
Schedule
and
and
Gas
Gasohol
Kerosene
1.
Gallons Delivered Tax Collected
(Taxable Sales)
5
2.
Taxable Use
5Q
3.
Gallons Delivered Tax Free to
PA Distributors (Resales)
6
4.
Gallons Exported
7
5.
Gallons Delivered Tax Exempt to
U.S. Gov’t
8
6.
Gallons Delivered Tax Exempt to PA
and its Political Subdivisions
9
7.
Gallons Delivered Tax Exempt to
Other Exempt Entities
10
8.
Total Disbursements
XXXXXXX
1096207100

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