Form 73 Mfd - Nebraska Multiple Schedule Of Disbursements
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3Nebraska Multiple Schedule of Disbursements
FORM 73 MFD
Taxpayer Name
FEIN
NE ID Number
Tax Period
Sample Oil Company
123456789
009876543
07/2012
VALID SCHEDULE CODES
VALID PRODUCT CODES
5
Gross gallons delivered tax and PRF fee paid to another licensed supplier, distributor, wholesaler, importer, or retailer
061 Nat. Gasoline (Denaturant)
160 Undyed Diesel
6
Gross gallons disbursed without tax or PRF fee to a licensed supplier, distributor, wholesaler, or exporter
065 Gasoline
228 Dyed Diesel
7
Gross gallons exported without tax or PRF fee to another state
123* Ethanol-Alcohol
B00 Undyed Biodiesel
8
Gross gallons delivered to U.S. Government or its agencies; or to the Metropolitan Transit Authority
124* Gasohol
D00 Dyed Biodiesel
10
Gross gallons delivered to a Native American residing on a reservation
125 Aviation Gasoline
170* Undyed Biodiesel Blend
13C Credit for tax-paid fuel sold to the U.S. Government
130 Aviation Jet Fuel
171* Dyed Biodiesel Blend
13J
Credit for tax-paid fuel sold pursuant to Form 91EX
142 Kerosene
*Refer to instructions for alternative product codes.
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Sch.
Bill of Lading
Document/ Bill of
Gross
Carrier Name
Carrier FEIN
Mode
Origin
Destination
Purchaser Name
Purchaser FEIN
Product Code
Code
Date
Lading No.
Gallons
5
CarrierName
123456789
J
T99NE1000
NE
PurchaserName
222333222
7/7/2012
2223
4,000
65
5
CarrierName
123456789
J
T99NE1000
NE
PurchaserName
222333222
7/5/2012
123456
2,000
160
13C
(Blank)
(Blank)
GS
(Blank)
(Blank)
RetailerName
456789123
7/31/2012
Various
500
124
13J
(Blank)
(Blank)
GS
(Blank)
(Blank)
RetailerName
456789123
7/31/2012
Various
300
160
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