Form Pet 374 - Annual Terminal Return
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1
2TENNESSEE DEPARTMENT OF REVENUE
ANNUAL TERMINAL RETURN
Account Number
FEIN
Filing
PET
Period
374
Location Address
Terminal Code
Due
Date
Make your check payable to the Tennessee
License Number
Department of Revenue for the amount shown
on Line 15 and mail to:
Tennessee Department of Revenue
Andrew Jackson State Office Bldg.
500 Deaderick Street
Nashville, TN 37242
For assistance, you may call in-state toll free
1-800-342-1003 or (615) 741-2594.
}
If this is an AMENDED RETURN,
please check the box at right
1. Total net gallons of diesel removed from terminal in bulk ........................................................................................
_______________________________
2. Total net gallons of diesel removed from terminal across terminal rack .................................................................
_______________________________
3. Total gallons removed from terminal (add lines 1 and 2) .........................................................................................
_______________________________
4. Total losses or unaccounted for gallons of diesel which exceed the sum of any gains (net gallons) .................
_______________________________
5. Loss Allowance Factor - Multiply Line 3 by 0.5% ...................................................................................................
_______________________________
6. If Line 4 is greater than Line 5, enter the difference; if Line 5 is greater than Line 4, enter zero ........................
_______________________________
.
$ ___________________
7. Special Tax - multiply Line 6 by $0.01 ......................................................................................................................
.
$ ___________________
8. Environmental Assurance Fee - multiply Line 6 by $0.004 .....................................................................................
.
$ ___________________
9. Diesel Tax - multiply Line 6 by $0.17 ........................................................................................................................
.
$ ___________________
10. Total Tax Due (add lines 7, 8, and 9) .......................................................................................................................
.
$ ___________________
11. Enter outstanding credit amount from previous Department of Revenue notice(s) ...............................................
.
{
If filed LATE, compute penalty at 5% of the tax (Line 10 minus Line 11) for each 1 to 30 DAY PERIOD or portion thereof for which
$ ___________________
12. Penalty
......
TAX IS DELINQUENT (Total penalty NOT TO EXCEED 25%.) Minimum penalty is $15 regardless of the amount of tax due or
whether there is any tax due.
.
$ ___________________
13. Interest (Line 10 minus Line 11 multiplied by
% per annum on taxes unpaid by the due date) ..................
.
$ ___________________
14. Excess Loss Penalty - If Line 4 exceeds 5% of Line 2, enter amount of Line 10 here ........................................
.
$ ___________________
15. TOTAL REMITTANCE AMOUNT (Total of lines 10, 12, 13, and 14; subtract Line 11 if applicable) .......................
Under penalties of perjury, I declare that I have examined this return, and to the best of my
FOR OFFICE
knowledge and belief, it is true, correct, and complete.
USE ONLY
Taxpayer's Signature
Date
Date
Signature of Preparer other than Taxpayer
Phone Number
Tax Preparer's Address
RV-R0009401
INTERNET (11-05)
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