Form Smf-10 - Supplier Of Motor Fuels Report Page 12

Download a blank fillable Form Smf-10 - Supplier Of Motor Fuels Report in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form Smf-10 - Supplier Of Motor Fuels Report with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

Division use only — DLN Stamp

Division use only — Date Stamp

Period

Attach to:

yyyy

Form SMF100,

Pursuant to NJSA 54:39-101 et seq

Supplier Schedule of Motor Fuels Tax Due

10-2010

SMF107

Schedule of Credits for Amounts Due from Delinquent Distributors for Gasoline

Supplier

Supplier FID #

Page

Date

Customer

Document

Product

Net

Gross

Invoiced

Total Tax Liability

Tax Received

Tax Outstanding

Delinquent

from Distributor

Customer

Shipped

FID Number

Number

Code

Gallons

from Distributor

Total Amount of Tax Outstanding Reported on This Page

Total Amount of All Outstanding Tax Delinquencies (on line 14, form SMF 100)

Certification of Supplier —

The undersigned certifies as follows: The above representations of Qualified Distributors are accurate to the best of my knowledge. My company will not

accept delayed remittances from the above Distributor(s) until notice is received from the Division of Taxation of requalification of the Distributor(s). My company will have no protection from

assessment of tax, penalty, and interest in the event that the above Distributor(s) make late remittances 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.

Signature of Authorized Representative

Printed Name of Signatory

Title of Signatory

Date Signed