Form 9114w - Made By Petroleum Wholesalers For Hsca Taxed Purchases
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1STATE OF DELAWARE
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STATEMENT OF PAYMENTS
Department of Finance
MADE BY PETROLEUM WHOLESALERS
Division of Revenue
Print Form
FOR HSCA TAXED PURCHASES
820 N. French Street
P.O. Box 2340
FORM 9114W
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.
Petroleum Total Monthly Gross Receipts: Month/Year
(a)
(b) $
(Must Equal Line 5 of Gross Receipts Coupon)
5.
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
*
If more space is needed, use Form 9114W Supplemental Line 5
6. Total Payments for HSCA Taxed Purchases:
b) $
c) $
x
7. Multiply Line 6(b) by 0.009.
(Line 6(b)
0.009) =
$
÷
8. Divide Line 6(c) by Line 7.
(Line 6(c)
Line 7) =
–
9. Subtract Line 8 from 1.0.
(1.0
Line 8) =
x
x
10. Multiply the product of Line 4(b) and Line 9 by 0.009. (Line 4(b)
Line 9
0.009) =
$
Enter the result of Line 10 on your Monthly Gross Receipts Coupon, Line 6.
I declare under penalties as provided by law that the information on this form and any attachments are true, correct and complete.
DATE
SIGNATURE
TITLE
(Revised 08/07/07)
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