Form Dr-309634 Sample - Local Government User Of Diesel Fuel Tax Return - 2015 Page 5
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800003
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DR-309634
R. 01/14
Page 5
Schedule of Receipts — Local Government User
Schedule Type/Product Type
Company Name
FEIN
Collection Period Ending
(mm/dd/yy)
Schedule Types:
Product Types:
065 Gasoline
226 High Sulfur Diesel Fuel - Dyed
B00
Undyed/Unblended
1A. Gallons Received - Tax Paid
124 Gasohol
227 Low Sulfur Diesel Fuel - Dyed
Biodiesel (B100)
167 Low Sulfur Diesel #2/
2A. Gallons Received - Tax Unpaid
D00
Dyed Biodiesel (B100)
Undyed/Blended Biodiesel
(B20, B10, B5, B2)
(1)
(2)
(3)
(4)
(5)
Name of Supplier
Date Received
Invoice Number
Gallons Received
Subtotal
* Department of Environmental Protection Number (DEPN)
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Parent category: Financial