Form Dr-309634 Sample - Local Government User Of Diesel Fuel Tax Return - 2015 Page 6

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DR-309634
R. 01/14
Page 6
Schedule of Receipts — Local Government User (continued)
Schedule Type/Product Type
Company Name
FEIN
Collection Period Ending
(mm/dd/yy)
(1)
(2)
(3)
(4)
(5)
Name of Supplier
Date Received
Invoice Number
Gallons Received
Total

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