Form Dr-309631 Sample - Terminal Supplier Fuel Tax Return - 2015 Page 4
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18DR-309631
R. 01/14
Page 4
Company Name
FEIN
Collection Period Ending
GALLONS
DIESEL
A. Gasoline
B. Undyed
C. Dyed
D. Aviation
1. Beginning physical inventory: .....................................
2. Receipts: (Page 5, Section I, Line 7) ..........................
3. Disbursements: (Page 5, Section II, Line 15) ...............
4. Transfers: ....................................................................
5. Gain or (Loss): ............................................................
6. Ending physical inventory: .........................................
7. Net taxable gallons: (Page 5, Section II, Line 14,
Columns A, B, and D) .................................................
8. Tax-paid purchases: (Page 5, Section I, Line 2) .........
9. Taxable gallons: (Line 7 minus Line 8) ........................
DOLLARS
State Tax Calculations
10. Gasoline: (Line 9, Column A times
)
.28525
Diesel: (Line 9, Column B times
0000
) ................................
.173
11. Aviation: (Line 9, Column D times
0000
) ....................
.069
12. Collection allowance -
Gasoline: (Line 10, Column A times
000000
)
.00314
Aviation: (Line 11, Column D times
0000
) ....................
.002
13. Collection allowance -
Diesel: (Line 10, Column B times
000000
) ..................
.0067
14. Net state fuel tax due: ................................................
DIESEL
Local Option - Tax and Collection
A. Gasoline
B. Undyed
C. Dyed
D. Aviation
Allowance Calculations - Gasoline
15. Local option tax entitled to collection allowance -
Schedule 5LO) ............................................................
16. Collection allowance - gasoline local option
tax: (Line 15, Column A times
0000
) ..........................
.011
17. Local option tax not entitled to collection allowance -
Schedule 5LO) ............................................................
18. Total local option tax due - Gasoline: (Line 15 minus
Line 16 plus Line 17) ..................................................
Local Option - Tax and Collection Allowance – Diesel
19. Local option tax entitled to collection allowance -
Diesel: (Line 9, Column B times
0000
) .......................
.07
20. Collection allowance: diesel local option tax:
(Line 19, Column B times
00000
) ...............................
.011
21. Local option tax not entitled to collection allowance -
Diesel: (Line 9, Column B times
0000
) .......................
.073
22. Total local option tax due - Diesel: (Line 19 minus
Line 20 plus Line 21) ..................................................
Total State and Local Option Tax Due Calculations
23. Total tax due - Gasoline: (Line 14, Column A
plus Line 18, Column A) .............................................
24. Total tax due - Diesel: (Line 14, Column B
plus Line 22, Column B) .............................................
25. Total tax due - Aviation: (Line 14, Column D) .............
26. Combined gasoline, diesel, and aviation fuel tax due: (Add Lines 23, 24, and 25. Carry to Page 3, Line 26.) ................
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