Form Dr-309634 Sample - Local Government User Of Diesel Fuel Tax Return

Form Dr-309634 Sample - Local Government User Of Diesel Fuel Tax Return - 2015 Page 3

00002

DR-309634

Mail To:

Local Government User of

Florida Department of Revenue

R. 01/14

Diesel Fuel Tax Return

5050 W Tennessee St

Page 3

Tallahassee FL 32399-0165

For Calendar Year:

2015

❏

FEIN:

920002015999900940270348300000000100002

License Number:

Collection Period Ending:

DOR USE ONLY

POSTMARK OR HAND-DELIVERY DATE

Return Due By

Late After

Complete Reverse Side of Return First

11.

Diesel fuel tax due: (Page 4, Part II, Line 7, Columns E plus G plus I) ......................................11. ________________________

CREDITS

12a. Diesel fuel tax credit: (Page 4, Part II, Line 10,

Columns D plus F plus H) ..................................................................

12a. _____________________

12b. Gasoline tax credit: (Page 4, Part I, Line 8) ......................................... 12b. _____________________

13.

Combined credits: (Line 12a plus Line 12b) ........................................................................... 13. ________________________

14.

Net tax due: (Line 11 minus Line 13) ....................................................................................... 14. ________________________

15.

Penalty: ................................................................................................................................... 15. ________________________

16.

Interest: ................................................................................................................................... 16. ________________________

17.

Total due with return: ................................................................................................................ 17. ________________________

18.

Amount to be refunded: ........................................................................................................... 18. ________________________

❏

Check here if you have electronically transmitted funds

Under penalty of perjury, I declare that I have read this return and the facts stated in it are true.

_____________________________________________________________________________

_________________

Signature of Preparer

Title

Date

_____________________________________________________________________________

_________________

Contact Person (Please Print)

Telephone Number