Form Smf - 10 Draft - Supplier Of Motor Fuels Report Page 16
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19Division use only — DLN Stamp
Division use only — Date Stamp
Month
Year
Pursuant to NJSA 54:39-101 et seq
10-2010
Schedule of Credits for Amounts Due from
SMF207
Delinquent Distributors for Diesel & Kerosene Sales
Attach Invoices or other proofs of Accounts Payable
page
of
for this form
Taxpayer
Taxpayer ID #
If there are more than 15 Delinquent Distributors, use additional SMF207s
Delinquent
Distributor's
Amount Due
Amount Received
Amount Outstanding
Distributor
Taxpayer ID #
from Distributor
from Distributor
from Distributor
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Total
Amount
Outstanding
Reported on this Page
Certification of Supplier —
The undersigned certifies as follows:
The above representations of Qualified Distributors are accurate to the
Total Amount of Outstanding
best of my knowledge.
My company will not accept delayed
Delinquencies
remittances from the above Distributor(s) until notice is received from
the Division of Taxation of requalification of the Distributor(s). My
Report this amount on Line 10, SMF200
company will have no protection from assessment of tax, penalty, and
interest in the event that the above Distributor(s) make late remitances
after the date of this schedule. If the above representations are
incorrect for any reason, my company is responsible for payment of the
tax, penalties, and interest due for this period.
Printed Name of Signatory
Signature of Authorized Representative of this Supplier
Title of Signatory
Date Signed
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