Form 73 Mfr - Nebraska Multiple Schedule Of Receipts

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Nebraska Multiple Schedule of Receipts
FORM 73 MFR
Taxpayer Name
FEIN
NE ID Number
Tax Period
Sample Oil Company
123456789
009876543
07/2012
VALID SCHEDULE CODES
VALID PRODUCT CODES
061 Nat. Gasoline (Denaturant)
160 Undyed Diesel
1
Gross gallons received with tax and PRF fee paid
065 Gasoline
228 Dyed Diesel
2
Gross gallons received without tax or PRF fee from a licensed producer, supplier, distributor, or importer
123* Ethanol-Alcohol
B00 Undyed Biodiesel
2A
Gross gallons of ethanol received without tax or PRF fee and delivered into tax-free terminal storage in Nebraska
124* Gasohol
D00 Dyed Biodiesel
3
Gross gallons imported without tax or PRF fee via transport or rail from another state
125 Aviation Gasoline
170* Undyed Biodiesel Blend
4
Gross gallons of ethanol imported without tax or PRF fee from another state and delivered into tax-free terminal
130 Aviation Jet Fuel
171* Dyed Biodiesel Blend
storage in Nebraska
*Refer to instructions for alternative product codes.
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)
Sch.
Bill of Lading
Document/ Bill of
Product
Carrier Name
Carrier FEIN
Mode
Origin
Destination
Seller Name
Seller FEIN
Gross Gallons
Code
Date
Lading No.
Code
2
CarrierName
123456789
J
T99NE1000
NE
SellerName
333222333
7/18/2012
2223
4,000
65
2
CarrierName
123456789
J
T99NE1000
NE
SellerName
333222333
7/28/2012
44
7,000
125
2
CarrierName
123456789
J
T99NE1000
NE
SellerName
333222333
7/5/2012
123456
2,000
160
2
CarrierName
123456789
J
NE
NE
SellerName
333222333
7/17/2012
54321
4,500
160
2A
CarrierName
123456789
J
NE
T99NE1000
SellerName
333222333
7/24/2012
62589
5,500
123
4
CarrierName
123456789
R
IA
T99NE1000
SellerName
333222333
7/26/2012
486
29,000
123

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