Form 83 Mfd - Nebraska Producer'S Schedule Of Disbursements
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1
2Nebraska Producer's Schedule of Disbursements
FORM 83 MFD
Producer's Name
FEIN
NE ID Number
Tax Period
Sample Oil Company
123456789
001234567
01/2012
VALID SCHEDULE CODES
VALID PRODUCT CODES
5
Gross gallons delivered tax-paid
6
Gross gallons disbursed without tax to a licensed supplier, distributor, wholesaler, or exporter
6R
Gross gallons transferred to another producer's Nebraska storage
061
Natural Gasoline Denaturant
7
Gross gallons exported without tax to another state
123 or E00 Ethanol-Alcohol
8
Gross gallons delivered to U.S. Government or its agencies; or to the Metropolitan Transit Authority
B00
Biodiesel
10
Gross gallons delivered to a Native American residing on a reservation
10F
Gross gallons transferred to a supplier's storage at a Nebraska terminal
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)
Sch.
Carrier
Purchaser
Bill of Lading
Document/ Bill of
Gross
Product
Carrier Name
Mode
Origin
Destination
Purchaser Name
Code
FEIN
FEIN
Date
Lading No.
Gallons
Code
7
Carrier Name
123456789
R
NE
CA
Buyer Name
222333222
1/13/2012
2497
15,000
123
5
Carrier Name
123456789
J
NE
NE
Buyer Name
222333222
1/18/2012
2223
7,000
123
5
Carrier Name
123456789
J
NE
NE
Buyer Name
222333222
1/17/2012
44
3,000
B00
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