Form 9114w - Statement Of Payments Made By Petroleum Wholesalers For Hsca Taxed Purchases

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STATE OF DELAWARE
STATEMENT OF PAYMENTS
Department of Finance
Print Form
MADE BY PETROLEUM WHOLESALERS
Division of Revenue
FOR HSCA TAXED PURCHASES
820 N. French Street
P.O. Box 2340
FORM 9114W SUPPLEMENTAL LINE 5
Wilmington, Delaware 19899-2340
THIS FORM IS TO BE ATTACHED TO PETROLEUM WHOLESALER’S MONTHLY GROSS RECEIPTS COUPON
TO SUBSTANTIATE PAYMENTS FOR HSCA TAXED PURCHASES
1.
Enter Federal Employee Identification Number
OR
Social Security Number
1-
-
2-
-
-
2.
Name
3.
Address
4.
Payments for All Petroleum Purchased
Employer ID No. /
HSCA Tax Paid
(a)
Name & Address
(b) Amount of Purchase
(c)
DE Business License No.
on Purchases
(Revised 08/07/07)

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