Form Dr-309631 Sample - Terminal Supplier Fuel Tax Return - 2015 Page 13
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1800007
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DR-309631
R. 01/14
Page 13
Schedule 12 — Ultimate vendor credits worksheet for reporting deliveries and exports of tax paid fuel
to consumers who qualify to purchase fuel tax-exempt
Schedule
Company Name
FEIN
Collection Period Ending
GALLONS
DIESEL
A. Gasoline
B. Undyed
C. Dyed
D. Aviation
1. Total gallons delivered to other tax exempt
entities (Schedule 10): .........................................
2. Total gallons delivered to U.S. Government tax
exempt - 500 gallons or more (Schedule 8): .......
3. Total gallons exported by other than
bulk transfer (Schedule 7A): ................................
4. Total gallons tax paid aviation fuel converted for
highway use (Schedule 5HW): .............................
5. Total gallons qualifying for credit:
(add Lines 1,2,3, and 4) .......................................
.28525
.173
.069
6. State fuel tax rate: ..............................................
7. State tax due: (Line 5 times Line 6) .....................
.00314
.0067
.002
8. Collection allowance rates for state tax: ...........
9. State tax collection allowance
calculation: (Line 7 times Line 8) .........................
10. Local option rate entitled to collection
.07
allowance: ............................................................
11. Portion of local option tax entitled to collection
allowance: (Line 5, Column B times Line 10) .......
.011
12. Local option collection allowance rate: ...............
13. Local option collection allowance
calculation: (Line 11 times Line 12) .....................
14. Local option tax rate not entitled to
.073
collection allowance: ...........................................
15. Portion of local option tax not entitled to collection
allowance: (Line 5, Column B times Line 14) ........
16. Ultimate vendor credit calculation:
a. Gasoline: (Line 7 minus Line 9) ........................
b. Diesel: (Line 7 minus Line 9 plus Line 11
minus Line 13 plus Line 15) .................................
c. Aviation: (Line 7 minus Line 9) .........................
Shared Collection Allowance Add-back
17. Enter the amount from Line 5 above (total gallons
qualifying for credit): If zero, skip to Line 24 ........
18. Enter the amount from Line 7, Page 4 of this
return (net taxable gallons): .................................
19. Gallons subject to shared collection allowance
calculation: (Line 17 minus 18). If negative, enter
zero and skip to Line 24 ......................................
20. State fuel tax rate: ...............................................
.28525
.173
.069
21. Tax subject to shared collection allowance:
(Line 19 times Line 20) .........................................
.00157
.00335
.001
22. Shared collection allowance add back rates: ......
23. Shared collection allowance add back:
(Line 21 times Line 22) .........................................
24. Allowable ultimate vendor credit
A. Gasoline: (Line 16A plus Line 23A) ..................
B. Diesel: (Line 16B plus Line 23B) ......................
C. Aviation: (Line 16C plus Line 23C) ..................
25. Total ultimate vendor credit amount: (Add Line 24A, Line 24B, and Line 24C. Carry forward to Page 3, Line 27.) . .......
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