Form Rev-1019 - Registered Distributor'S Receipt Schedule

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REGISTERED DISTRIBUTOR’S RECEIPT SCHEDULE
Use this form for Schedules 1, 1F, 2, 2F, 3 and 4
AND ALTERNATIVE
BUREAU OF MOTOR
FUEL TAXES
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)
065 Gasoline
142 Kerosene - Clear
1
PA Tax-Paid Gallons Received and Placed in Inventory
124 Gasohol
073 Low Sulfur Kerosene - Dyed
1F
PA Tax-Paid Gallons Received and Direct Shipped to Customers
125 Aviation Gasoline
160 Low Sulfur Diesel - Clear
130 Jet Fuel
227 Low Sulfur Diesel Fuel - Dyed
2
Tax-Free Gallons Received (Resales) and Placed in Inventory
123 Ethanol
170 Biodiesel - Clear
2F
Tax-Free Gallons Received and Direct Shipped to Customers
A separate report must be filed for each product type. Complete
3
Gallons Imported & Direct-Shipped to PA Customers
a separate form for each schedule required and indicate type of
4
Gallons Imported into Tax-Free Storage in PA
schedule and type of product in the space provided.
1
2
3
4
5
6
7
8
9
10
Point of
Carrier’s
Carrier’s
Acquired
Seller’s
Date
Document
Net
Gross
Origin
Dest.
Name
FEIN
Mode
From
FEIN
Received
Number
Gallons
Gallons
City & State
City & State
REV-1019 MF (06-13)
TOTAL

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