06-187
-- AMENDED --
PRINT
(Rev.3-06/3)
b.
<choose one>
a.
DO NOT WRITE IN SHADED AREAS
TYPE or PRINT
TEXAS SCHEDULE OF STATE DIVERSIONS OF
c. Taxpayer number
d. Filing period
UNDYED DIESEL FUEL/GASOLINE
(Item 21)
f.
d. Taxpayer name
1. Transporter name
2. Transporter taxpayer number
LOCATOR NUMBER
3. Purchaser name
4. Purchaser taxpayer number
5. Product type
6. Mode
7. Original destination
8. Revised destination
9. Diversion number
10. Date removed
11. Shipping doc. no.
12. Terminal control number
13. Invoiced gallons
LOCATOR NUMBER
1. Transporter name
2. Transporter taxpayer number
3. Purchaser name
4. Purchaser taxpayer number
5. Product type
6. Mode
7. Original destination
8. Revised destination
9. Diversion number
10. Date removed
11. Shipping doc. no.
12. Terminal control number
13. Invoiced gallons
1. Transporter name
2. Transporter taxpayer number
LOCATOR NUMBER
3. Purchaser name
4. Purchaser taxpayer number
5. Product type
6. Mode
7. Original destination
8. Revised destination
9. Diversion number
10. Date removed
11. Shipping doc. no.
12. Terminal control number
13. Invoiced gallons
1. Transporter name
2. Transporter taxpayer number
LOCATOR NUMBER
3. Purchaser name
4. Purchaser taxpayer number
5. Product type
6. Mode
7. Original destination
8. Revised destination
9. Diversion number
10. Date removed
11. Shipping doc. no.
12. Terminal control number
13. Invoiced gallons
1. Transporter name
2. Transporter taxpayer number
LOCATOR NUMBER
3. Purchaser name
4. Purchaser taxpayer number
5. Product type
6. Mode
7. Original destination
8. Revised destination
9. Diversion number
10. Date removed
11. Shipping doc. no.
12. Terminal control number
13. Invoiced gallons
LOCATOR NUMBER
1. Transporter name
2. Transporter taxpayer number
3. Purchaser name
4. Purchaser taxpayer number
5. Product type
6. Mode
7. Original destination
8. Revised destination
9. Diversion number
10. Date removed
11. Shipping doc. no.
12. Terminal control number
13. Invoiced gallons
TOTAL INVOICED GALLONS
(Sum of Item 13)
FOR THIS PAGE ONLY