Fillable Form 775 - Maryland Motor Fuel Tax - Movement Of Petroleum Products printable pdf download

Form 775 - Maryland Motor Fuel Tax - Movement Of Petroleum Products

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FORM

MARYLAND

MOVEMENT OF PETROLEUM PRODUCTS

775

MOTOR FUEL

TAX

Month

Petroleum Transporter Name ________________________________

This report must be filed by the end of the month following the month of

activity reported. Failure to file reports could result in cancellation of your

Petroleum Transporter Account No.

petroleum transporter privileges.

SEE INSTRUCTIONS ON REVERSE SIDE

METHOD OF

LOADING TERMINAL

FRT.PD. BY

CONSIGNOR - NAME ADDRESS

CONSIGNEE- NAME

GALLONS

PRODUCT CODE

DELIVERY

ADDRESS

S/P

ADDRESS OF DELIVERY POINT

SIGNATURE AND VERIFICATION: I certify under the penalties of perjury that this has been examined by me and to the best of my knowledge and belief is a true, correct, and

complete return.

By: _________________________________________________

Title: ______________________________

Date: ________________________

For more information:

Visit our Web site at or call Taxpayer Service at 410-260-7980 in Central Maryland or 1-800-638-2937 from elsewhere. Send faxes to 410-974-3608.

Mail to: Comptroller of Maryland, Revenue Administration Division, PO Box 1751, Annapolis, MD 21404-1751.

COM/RAD 775

Rev 6/13