Form Dr-904 - Pollutants Tax Return - 2015
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600001
0000001
DR-904
Mail To:
Pollutants Tax Return
R. 01/13
Florida Department of Revenue
5050 W. Tennessee Street
Rule 12B-5.150
For Calendar Year:
2015
Tallahassee, Florida 32399-0165
Florida Administrative Code
Effective 01/13
DOR USE ONLY
POSTMARK OR HAND DELIVERY DATE
Check here if amending return
920002015999900340270313300000000100002
License Number:
Name
FEIN:
Address
City/St/ZIP
Collection Period Ending:
Use black ink.
Handwritten Example
Typed Example
0 1 2 3 4 5 6 7 8 9
0123456789
Return Due By
Late After
Complete Reverse Side of Return First
,
,
34.
Total tax due: (Enter the results of adding Columns 1,2,3, and 4, on Page 2, Line 33) ............
,
,
35.
Credit memos issued by the Department of Revenue: .............................................................
TOTAL DUE WITH RETURN CALCULATION
,
,
36.
Total tax due: .............................................................................................................................
,
,
37.
Penalty: .....................................................................................................................................
,
,
38.
Interest: .....................................................................................................................................
,
,
39.
Total due with return: .................................................................................................................
Important Notice: Crude oil produced at the well site and exported from that site by the producer exclusively by pipeline, truck, or rail
without intermediate stoppage or storage is the only pollutant allowed an export provision under the Coastal Protection Fund.
Under penalty of perjury, I declare that I have read this application and the facts stated in it are true.
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
Name of Preparer (Print)
Signature of Preparer
Telephone Number
FEIN
Date
Mail To:
Pollutants Tax Return Coupon
DR-904
Florida Department of Revenue
R. 01/13
For Calendar Year:
2015
5050 W Tennessee St
COMPLETE and MAIL with your RETURN/PAYMENT.
Tallahassee FL 32399-0165
on your check.
Florida Department of Revenue
FEIN
ENTER BUSINESS NAME:
US Dollars
Cents
AMOUNT DUE FROM LINE 39 IF
,
,
CREDIT DUE ENTER 0
Name
Address
FOR COLLECTION
M M D D
Y
Y
City/St/ZIP
PERIOD ENDING
DR-904
Do Not Write in the Space Below
9200 0 20159999 0034027031 3 3000000001 0000 2
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