Form Dr-309635 Sample - Blender Fuel Tax Return

Form Dr-309635 Sample - Blender Fuel Tax Return - 2015 Page 3

00002

DR-309635

Mail To:

Blender Fuel Tax Return

Florida Department of Revenue

R. 01/14

5050 W Tennessee St

Page 3

Tallahassee FL 32399-0165

For Calendar Year:

2015

❑

FEIN:

920002015999900950270356300000000100002

License Number:

Collection Period Ending:

DOR USE ONLY

POSTMARK OR HAND-DELIVERY DATE

Return Due By

Late After

Complete Reverse Side of Return First

24.

Combined gasoline, diesel, aviation and local option fuel tax due: (Page 4, Line 24) ....................24. ________________________

Credits

25.

Ultimate vendor credits: (Page 13, Line 25) ............................................. 25. _______________________

26.

Credit memos issued by the Department of Revenue: ............................ 26. _______________________

Total Due With Return Calculation

27.

Tax due with return: (Line 24 minus Lines 25 and 26) ....................................................................27. _______________________

28.

Penalty: ...........................................................................................................................................28. _______________________

29.

Interest: ...........................................................................................................................................29. _______________________

30.

Total due with return: (Line 27 plus Line 28 plus Line 29) ...............................................................30. _______________________

❑

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.

_______________________________________________________________________________________________________________________

Name of Preparer (Print)

Signature of Preparer

Telephone Number

FEIN

Date