Form Rev-1020 - Registered Distributor'S Disbursement Schedule

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REGISTERED DISTRIBUTOR’S DISBURSEMENT SCHEDULE
Use this form for Schedules 5, 5Q, 6, 7, 8, 9 and 10.
AND ALTERNATIVE
BUREAU OF MOTOR
FUEL TAXES
Submit Schedule 7 in duplicate and use a separate sheet for each state.
PO BOX 280646
Read instructions on reverse side.
HARRISBURG PA 17128-0646
DISTRIBUTOR’S NAME
FEIN:
SCHEDULE TYPE:
MONTH/YEAR:
SCHEDULE TYPE
PRODUCT TYPE (CIRCLE ONE)
5
Gallons Delivered, Tax Collected (Taxable Sales)
065 Gasoline
142 Kerosene - Clear
124 Gasohol
073 Low Sulfur Kerosene - Dyed
5Q
Taxable Use
125 Aviation Gasoline
160 Low Sulfur Diesel - Clear
6
Gallons Delivered Tax-Free to PA Distributors (Resales)
130 Jet Fuel
227 Low Sulfur Diesel Fuel - Dyed
7
Gallons Exported
090 Additives - Misc.
170 Biodiesel - Clear
8
Gallons Delivered Tax-Exempt to U.S. Government
A separate report must be filed for each product type. Complete a
9
Gallons Delivered Tax-Exempt to PA & Political Subs
separate form for each schedule and indicate type of schedule and
type of product in the space provided.
10
Gallons Delivered Tax-Exempt to Other Exempt Entities
1
2
3
4
5
6
7
8
9
10
11
Point of
Carrier’s
Carrier’s
Terminal
Sold
Purchaser’s
Date
Document
Net
Gross
Origin
Dest.
FEIN
To
Shipped
Name
Mode
Code
FEIN
Number
Gallons
Gallons
City&State
City&State
TOTAL
REV-1020 MF (06-13)

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