Form Dr-309635 Sample - Blender Fuel Tax Return - 2015 Page 4
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14DR-309635
R. 01/14
Page 4
Company Name
FEIN
Collection Period Ending
GALLONS
DIESEL
A. Gasoline
B. Undyed
C. Dyed
D. Aviation
1.
Beginning physical inventory: (must agree with
prior month’s ending inventory) .....................
2.
Receipts: (Line 3, Section I, Page 5) ..............
3.
Disbursements:
(Line 4, Section II, Page 5) ..............................
4.
Transfers: ........................................................
5.
Gain or (Loss): .................................................
6.
Ending physical inventory: .............................
7.
Net taxable gallons: (Line 1, Section I, Page 5,
Column A - Gasoline, Column B - Diesel, and
Column D - Aviation) .......................................
State Tax Calculations
DOLLARS
8.
Gasoline: (Line 7, Column A times
00 00
),
.28525
and Diesel: (Line 7, Column B times
0000
) ..
.173
9.
Aviation: (Line 7, Column D times
0000
) .......
.069
10. Collection allowance -
Gasoline: (Line 8, Column A times
000 0
)
.00314
Aviation: (Line 9, Column D times
) ...
.002
11. Collection Allowance -
Diesel: (Line 8, Column B times
000000
) ......
.0067
12. Net state fuel tax due: ....................................
Local Option Tax Collection Allowance
DIESEL
Calculations – Gasoline
A. Gasoline
B. Undyed
C. Dyed
D. Aviation
13. Local option tax entitled to collection
allowance - Gasoline: (Schedule 11, Column C
........................................
14. Collection allowance - gasoline local option
tax: (Line 13, Column A times
0000
) .............
.011
15. Local option tax not entitled to collection
allowance - Gasoline: (Schedule 11, Column E
........................................
16. Total local option tax due - Gasoline: (Line 13
minus Line 14 plus Line 15) ............................
Local Option Tax Collection Allowance
Calculations – Diesel
17. Local option tax entitled to collection allowance
- Diesel: (Line 7, Column B times
000
) ...........
.07
18. Collection allowance - diesel local option tax:
(Line 17, Column B times
0000
) .....................
.011
19. Local option tax not entitled to collection
allowance - Diesel: (Line 7, Column B
times
0000
) ....................................................
.073
20. Total local option tax due - Diesel: (Line 17
minus Line 18 plus Line 19) ............................
Total State and Local Option Tax Due
Calculations
21. Total tax due - Gasoline: (Line 12, Column A
plus Line 16, Column A) ..................................
22. Total tax due - Diesel: (Line 12, Column B plus
Line 20, Column B) .........................................
23. Total tax due - Aviation:
(Line 12, Column D) .........................................
24. Combined gasoline, diesel, aviation, and local option fuel tax due: (Add Lines 21, 22, and 23. Carry to Page 3, Line 24.) ......
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