Form Dr-309633 Sample - Mass Transit System Provider Fuel Tax Return

DR-309633

R. 01/13

Page 4

Company Name

FEIN

Collection Period Ending

(mm/dd/yy)

Rate 1: Tax entitled to credit/refund for mass transit use is

per gallon.

A. Mass Transit

Part I - Gasoline

1. Beginning physical inventory: ........................................................................

2. Receipts: ........................................................................................................

3. Disbursements/Use: ......................................................................................

a. Off-highway use (does not qualify for credit) .........................................

b. To other local government users (does not qualify for credit) ................

c. On-highway use .....................................................................................

4. Gain or loss: ...................................................................................................

5. Ending physical inventory: .............................................................................

6. Gallons entitled to credit: (Line 3c minus Line 4 gain) ...................................

7. Gasoline credit: (Carry to Page 3, Line 10b) ..................................................

Credit calculation (Rate 1 (from above) times Line 6 = Line 7)

Mass Transit

Part II - Diesel

B. Undyed Diesel

C. Dyed Diesel