Form Mfd-04 - State Of Georgia Computation Of Prepaid State Tax On Motor Fuel Sales & Use Page 6
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Form MFD-04 (Rev. 6/13)
Page 5
GEORGIA MOTOR FUEL TAX MULTIPLE
SCHEDULES OF RECEIPTS
DISTRIBUTORS NAME: _____________________
LICENSE NO.: _____________________
FEIN: _____________________
SCHEDULE TYPE: _____________________
MONTH OF: _____________________ 20 ______
PRODUCT CODE
(CHECK ONE)
TYPE OF SCHEDULE
1.
GALLONS RECEIVED IN GA – TAX
054 PROPANE (LPG)
130 JET FUEL
227 LS/DIESEL - DYED
PAID
065 GASOLINE
145 LS/KEROSENE – CLEAR
167 LS/DIESEL - CLEAR
2.
GALLONS RECEIVED IN GA FROM
LICENSED MOTOR FUEL
124 GASOHOL
226 HS/DIESEL – DYED
224 COMPRESSED NATURAL GAS (CNG)
DISTRIBUTORS – TAX UNPAID
3.
GALLONS IMPORTED FROM
125 AVIATION GASOLINE
284 BIO DIESEL (CLEAR)
225 LIQUID NATURAL GAS (LNG)
ANOTHER STATE
_________________
123 ALCOHOL
_____________________ OTHER SPECIFY, SEE FTA PRODUCT CODE LIST
4.
N/A
(2)
(5)
(6)
(7)
(8)
(11)
(4) POINT OF
(1)
(3)
CARRIER
ACQUIRED
SUPPLIER’S GA.
DATE
DOCUMENT
BILLED
ORIGIN
DESTINATION
MODE
CARRIER NAME
FEIN
FROM
LICENSE NUMBER
RECEIVED
NUMBER
GALLONS
(CITY, STATE)
(CITY)
TOTALS
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