Form 199-D - Schedule 4 - Special Fuel Delivered Outside Of Oklahoma

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Form 199-D

Revised 1-2012

Motor Fuel Division - Oklahoma Tax Commission

Schedule 4

Special Fuel Delivered Outside of Oklahoma

This report must be attached to summary of OTC Form 199.

List items to each state on separate reports. Total of reports to appear on Form 199, Line 9.

Name of Special Fuel Dealer or User

OTC License Number

Report for the Month/Year of

Street Address or Box Number

City or Town

State

Zip

Name of State Exported To

Delivery

Tank Car No.

Gallons of

Invoice

or Transporter

LPG, Butane,

Date

Number

Sold To

City, State

OTC No.

Propane, etc.

Total Gallons Special Fuel Delivered Outside of Oklahoma (Enter on Form 199, Line 9)

I/We declare under the penalties of perjury that this schedule 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 existing tax law requiring the filing of this schedule.

______________________________________________________________________

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Dealer or User

The Oklahoma Tax Commission is not required by law (Title 68) to advise taxpayers of subsequent changes in the Uniform Tax Code.