Form Dmf-26 - Monthly Carrier'S Report Of Liquid Fuel And Fuels Delivered
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2DMF-26 (08-13)
Dept. Use Only
MONTHLY CARRIER’S REPORT OF
BUREAU OF MOTOR AND
LIQUID FUEL AND FUELS DELIVERED
ALTERNATIVE FUEL TAXES
PO BOX 280646
HARRISBURG PA 17128-0646
Tele: (717) 346-9416
Fax: (717) 787-6261
Complete and attach enclosed schedules.
See instructions on reverse side of this report for accompanying schedules.
CARRIER’S NAME
FEIN
MONTH/YEAR
STREET
CITY
STATE
ZIP
o
Check here if new address:
1. Total gallons of petroleum product loaded at a PA terminal or bulk plant and
delivered to another state (attach Schedule 1A).
2. Total gallons of petroleum product loaded at an out-of-state terminal or
bulk plant facility and delivered in Pennsylvania (attach Schedule 2A).
3. Total gallons of petroleum product loaded at a PA terminal or bulk plant and
delivered in Pennsylvania (attach Schedule 3A).
4. Total gallons petroleum product transported (total of Lines 1
through 3).
I declare under penalties of perjury that this report (including any accompanying schedules and statements) has been
examined by me, and to the best of my knowledge and belief is a true, correct and complete report.
(Authorized Signature)
(Title)
(Telephone Number)
(Date)
This report must be filed with the PA Department of Revenue, Bureau of Motor and Alternative Fuel Taxes,
PO Box 280646, Harrisburg, PA 17128-0646 on or before the last day of each month following the report
period. Telephone inquiries should be made to 800-482-4382 or FAX 717-787-6261.
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