Form 06-177 - Amended Schedule Of Tax-Exempt Blending Materials - Diesel Fuel

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06-177
-- AMENDED --
(Rev.3-06/3)
b.
PRINT
07146
Diesel Fuel
a.
DO NOT WRITE IN SHADED AREAS
TYPE or PRINT
TEXAS SCHEDULE OF TAX-EXEMPT
c. Taxpayer number
d. Filing period
BLENDING MATERIALS - DIESEL FUEL
(Item 8)
f.
e. Taxpayer name
1. Transporter name
2. Transporter taxpayer number
LOCATOR NUMBER
3. Seller name
4. Seller taxpayer number
5. Product type
6. Gallons of blending materials
1. Transporter name
2. Transporter taxpayer number
LOCATOR NUMBER
3. Seller name
4. Seller taxpayer number
5. Product type
6. Gallons of blending materials
1. Transporter name
2. Transporter taxpayer number
LOCATOR NUMBER
3. Seller name
4. Seller taxpayer number
5. Product type
6. Gallons of blending materials
LOCATOR NUMBER
1. Transporter name
2. Transporter taxpayer number
3. Seller name
4. Seller taxpayer number
5. Product type
6. Gallons of blending materials
1. Transporter name
2. Transporter taxpayer number
LOCATOR NUMBER
3. Seller name
4. Seller taxpayer number
5. Product type
6. Gallons of blending materials
1. Transporter name
2. Transporter taxpayer number
LOCATOR NUMBER
3. Seller name
4. Seller taxpayer number
5. Product type
6. Gallons of blending materials
1. Transporter name
2. Transporter taxpayer number
LOCATOR NUMBER
3. Seller name
4. Seller taxpayer number
5. Product type
6. Gallons of blending materials
1. Transporter name
2. Transporter taxpayer number
LOCATOR NUMBER
3. Seller name
4. Seller taxpayer number
5. Product type
6. Gallons of blending materials
TOTAL INVOICED GALLONS
(Sum of Item 6)
FOR THIS PAGE ONLY

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