Form 72a089 - Licensed Gasoline Dealer'S Monthly Report

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72A089 (7-07)

FOR DEPARTMENT USE ONLY

LICENSED GASOLINE DEALER’S

Commonwealth of Kentucky

MONTHLY REPORT

5 4

__ __ __ __ __ __ / __ __ / __ __ / __ __

DEPARTMENT OF REVENUE

Account Number

Tax

Mo.

Yr.

➤ See Instructions on Reverse

Name and Address of Dealer

Check here for address change

Gasoline Dealer's Number GL__ __ __ __

Federal

Employer ID Number __ __ – __ __ __ __ __ __ __

Report for (mm/yy) _________________________________

(

)

Telephone Number __________________________________

Check Here if EFT Payment

(

)

Contact Person

Fax Number _______________________________________

PART I—Computation of Gasoline Gallons Subject to Tax

Attach

COLUMN A

COLUMN B

COLUMN C

RECEIPTS

In gallons

Schedule

1. Gasoline purchased in Kentucky (Form 72A179) ..................................

2. a. Gasoline sold for import into Kentucky

(Supplier's Report) (Form 72A178) ....................................................

b. Gasoline imported into Kentucky from other states (Form 72A179)

c. Total imports (add lines 2a and line 2b) .............................................

3. Gasoline disbursements from terminal storage (Form 72A179) ...........

4. Receipts of unreported alcohol or other additives (Form 72A179) ......

5. Total gasoline received (add lines 1, 2c, 3 and 4) ................................

DEDUCTIONS

6. Gasoline exported from Kentucky (Form 72A178) ...............................

7. Gasoline sold to Kentucky licensed dealers (Form 72A178) ................

8. Gasoline sold to U.S. government (Form 72A178) ................................

9. Gasoline lost through accountable losses (Approved Form 72A078) ..

10. Total gasoline deductions (add lines 6, 7, 8 and 9) ..............................

11. Total gasoline gallons subject to tax (line 5 minus line 10) ..........................................................................................................

PART II—Tax Computation

12. Gross tax liability (line 11 times rate per gallon) .............................................................................................................................

13. Tax rate adjustment for gasoline gallons inventory held in wholesale bulk storage on the last day of the period

(rate increase (decrease) __________ times __________ gallons) ................................................................................................

14. Tax due after tax rate adjustment (line 12 plus line 13) ...................................................................................................................

15. Nonhighway dealer credits

a. Sales of gasoline for agicultural purposes (Form 72A178)

(gallons on Schedule 10I _________________ times tax rate) .......................................................

$ (

)

16. Total nonhighway dealer credits (total of line 15) ............................................................................................................................

$ (

)

17. Tax due after credits (line 14 minus line 16) .....................................................................................................................................

18. Dealer compensation allowance (2¼% of line 17 if report and payment are timely submitted) ...................................................

$ (

)

19. Net tax due after allowable compensation (line 17 minus line 18) ..................................................................................................

20. Credit(s) for previous payments and other authorized credits (attach a copy of authorization) ...................................................

$ (

)

21. Total tax due (overpayment) (line 19 minus line 20) ......................................................................................................................

PART III—Statistical Gallons

➤

1. Gasoline imported into Kentucky (Kentucky tax paid to supplier) Form 72A179 (Schedule 1).

➤

2. Fuel-grade alcohol gallons blended or purchased for blending with gasoline during the above report period.

Make check payable to: KENTUCKY STATE TREASURER.

IMPORTANT NOTICE ➤

Mail report and check to: KENTUCKY DEPARTMENT OF REVENUE, FRANKFORT, KENTUCKY 40619.

I, the undersigned, a principal officer of the above-named licensee, have examined this report and it is, to the best of my knowledge and belief, a true,

correct and complete report.

Signature

Print Name

Title

Date