Form Pet 350 - Distributor Monthly Fuel Tax Return Page 4
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10Disbursements Schedule - Distributor Fuel Tax Return (Attach to PET 350)
Company Name:
FEIN:
Account Number:
Month of (MM-YY):
Tennessee Department of Revenue
Product Type (Circle One)
SCHEDULE TYPE
_________
65 GASOLINE
5. GALLONS SOLD TAX COLLECTED
122 BLENDING COMPONENTS (TRANSMIX)
5F. DYED DIESEL GALLONS SOLD FOR TAXABLE PURPOSES
123 ALCOHOL
5H. GALLONS SOLD AS EXPORT FROM IN-STATE TERMINALS (TN TAX COLLECTED)
124 GASOHOL
6D. GALLONS SOLD EXEMPT TO BONDED IMPORTERS
125 AVIATION GASOLINE
6H. GALLONS SOLD OR EXCHANGED WITH QUALIFIED REFINER
130 JET FUEL
6J. GALLONS DELIVERED TAX-FREE TO TN REFINERY
142 KEROSENE
7A. GALLONS EXPORTED - DESTINATION STATE TAX PAID (TN REFINERY INCLUDED)
160 UNDYED DIESEL
8. GALLONS SOLD TO U.S. GOV'T TAX-EXEMPT
226 DIESEL (HIGH SULFUR DYED)
9. GALLONS SOLD TO STATE & LOCAL GOV'T
227 DIESEL (LOW SULFUR DYED)
10A. GALLONS SOLD TO OTHER TAX-EXEMPT ENTITIES
____ OTHER (SEE ITA PRODUCT CODE LIST)
10E. GALLONS SOLD TO CUSTOMERS REPRESENTING UNCOLLECTIBLE FUEL TAXES
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)
NAME
CARRIER
POINT OF
TERMINAL
SOLD
PURCHASER
DATE
DOCUMENT
NET
GROSS
BILLED
CARRIER
FEIN
MODE
ORIGIN
DESTINATION
CODE
TO
FEIN
SHIPPED
NUMBER
GALLONS
GALLONS
GALLONS
PAGE __________ OF __________
TOTAL
RV-F1400701
INTERNET 4-03
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