Form Dr-309635 Sample - Blender Fuel Tax Return - 2015 Page 5
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1400003
DR-309635
R. 01/14
Page 5
Company Name
FEIN
Collection Period Ending
GALLONS
From
DIESEL
Schedule
Section I - Receipts: (see instructions)
A. Gasoline
B. Undyed Diesel
C. Dyed
D. Aviation
1.
Total product received or blended Florida
2B.
tax unpaid: ..............................................
2.
All other gallons received tax-paid (no
schedule required): ..................................
3.
Total Receipts: (Add Lines 1 and 2. Carry
forward to Line 2, Page 4.) ......................
From
DIESEL
Section II - Disbursements and Uses:
Schedule
(see instructions)
A. Gasoline
B. Undyed Diesel
C. Dyed
D. Aviation
1.
Gallons delivered or consumed subject to
additional local taxes: .............................
2.
Gallons of aviation fuel converted to
5HW.
highway use: ...........................................
3.
All other gallons delivered or consumed:
(no schedule required) .............................
4.
Total disbursements: (Add
Lines 1 through 3. Carry forward to
Line 3, Page 4.) .......................................
From
DIESEL
Section III - Gasohol/Gasoline Blend
Schedule
Production:
A. Gasoline
B. Undyed Diesel
C. Dyed
D. Aviation
1.
Number of gallons of previously
taxed gasoline blended to produce
...................................
......
produced (Add Lines 1 and 2.): ...............
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