Form Mfd-04 - State Of Georgia Computation Of Prepaid State Tax On Motor Fuel Sales & Use Page 5

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Form MFD-04 (Rev. 6/13)
Page 4
STATE OF GEORGIA GEORGIA MOTOR FUEL
TAX REPORT CALCULATION OF TAXES DUE
License #: _____________________
Period: ____________ To: ____________
Report gallons from lines 13-15 (Page 1) and lines 14-15 (Page 2) of the Motor Fuel Tax Report.
NUMBER OF
RATE PER
TAX AMOUNT
*(LESS VENDOR’S
Net Tax $
GALLONS
GALLON
DUE
COMPENSATION )
1.
Gasoline
Gals. @ 7 ½ ¢
1.
Gals. @ 7 ½ ¢
2.
Fuel Oils-Clear
2.
Gals. @ 7 ½ ¢
Fuel Oils-
3.
3.
Dyed
Gals. @ 7 ½ ¢
4.
L.P.G.
4.
Gals. @ 7 ½ ¢
5.
Special Fuel **
5.
Gals. @ 1 ¢
6.
Aviation Gas
6.
Gals. @ 7 ½ ¢
7.
Aviation Gas
7.
4% Net Prepaid State Tax Amount Due (Line 1-5) ....................................................................................................
8.
8.
(See page 3 of this report for reporting instructions)
3% Net Prepaid State Tax Amount Due (Line 6-10) ..................................................................................................
9.
9.
(See page 3 of this report for reporting instructions)
10. Add $50.00 if filed after the 20th day of the following month:................................................ 10.
11. Add 10% penalty on taxes if filed after the 20th day of the following month:......................... 11.
12. Add interest at 1% per month or part thereof on taxes due ...................................................... 12.
13. Subtotal: Late filing penalty, interest and late payment penalty:...............................................................
13.
14. TOTAL AMOUNT OF TAX DUE ......................................................................................................................... 14.
STATE OF GEORGIA:
This is to certify that the information contained herein and any additional information attached hereto is true and correct to the best of
my knowledge and belief.
_________________________
______________________
_________________
SIGNATURE
TITLE
PHONE
th
*
Allowance of 1% (.01) of the first 7 ½ cents per gallon is allowed only if payment is received by the 20
day of the month.
** Include all sales/use of CNG on the Special Fuel Line.

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