Form 06-168-A - Texas Fuels Tax Report Page 3
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406-168-B
BBBB
(Rev.8-11/6)
b.
*** AMENDED ***
06111
Gasoline Supplier
a.
Please do not write in space above
f.
e. Filing period
TEXAS FUELS TAX REPORT - Page 2
--For 2004 and later
c. Taxpayer number
d. Taxpayer name
ENTER WHOLE GALLONS
SECTION II - DISBURSEMENTS
(See instructions)
10. Blended gallons sold
(from attached Schedule, Form 06-152)
10.
11. Gallons sold to unlicensed entities in the bulk transfer/terminal system -- tax
collected by supplier/permissive supplier
(from attached Schedule, Form 06-153)
11.
12. Gallons removed from IRS Registered Terminal including deliveries to
company owned stores - tax collected by supplier/permissive supplier
12.
(from attached Schedule, Form 06-154)
13. Gallons of dyed diesel fuel sold tax free to license holders or removed
from IRS registered terminal
(from attached Schedule, Form 06-155)
13.
14. Gallons sold tax-free to aviation fuel dealers
(from attached Schedule, Form 06-156)
14.
15. Gallons exported
(from attached Schedule, Form 06-157)
15.
16. Gallons sold tax-free for export
(from attached Schedule, Form 06-158)
16.
17. Gallons sold tax-free to exempt entities
(from attached Schedule, Form 06-159)
17.
18. Gallons of dyed diesel fuel sold on a signed statement
18.
(from attached Schedule, Form 06-160)
19. Other tax-free sales and uses of dyed diesel fuel
(no schedule)
19.
20. Taxable sales and uses of dyed diesel fuel and gallons subject to backup tax
20.
(no schedule)
21. State diversions of undyed diesel fuel/gasoline (plus or minus)
(from attached Schedule, Form 06-161)
21.
22. TOTAL FOR SECTION II
(Add Items 10 through 21)
22.
SECTION III - TAX CALCULATION
23. Taxable gallons
(Total of Items 5, 11, 12, 20 and 21.)
23.
24. Gallons received in IRS registered terminal Texas tax paid
24.
25. Bad debts
(from attached Schedule, Form 06-163)
25.
26. Credit for gallons purchased tax-paid and sold tax-free
26.
27. Tax-paid gallons lost by fire, theft or accident
27.
28. Other tax exempt uses on which Texas tax was previously paid
28.
29. Adjusted Taxable Gallons
(Item 23 minus Items 24, 25, 26, 27 and 28)
29.
30. Allowance for handling for the gallons on
which tax is timely paid
(Multiply Item 29 by
)
30.
31. Net taxable gallons
(Item 29 minus Item 30 plus Item 7)
31.
$
32. Total tax due
(Item 31 at
per gallon)
32.
Daytime phone (Area code and no.)
I declare that the information in this document and any attachments is true and correct to the
best of my knowledge and belief.
Officer, director or authorized agent
Print or type name
Date
REPORT MUST BE SIGNED FOR REFUND TO BE ISSUED.
Return to Item 33 to complete form
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