Form Mfd-04 - State Of Georgia Computation Of Prepaid State Tax On Motor Fuel Sales & Use Page 7

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Form MFD-04 (Rev. 6/13)
Page 6
GEORGIA MOTOR FUEL TAX MULTIPLE
SCHEDULES OF DISBURSEMENTS
DISTRIBUTORS NAME: _____________________
LICENSE NO.: _____________________
FEIN: _____________________
SCHEDULE TYPE: _____________________
MONTH OF: _____________________ 20 ______
(CHECK ONE)
TYPE OF SCHEDULE
PRODUCT CODE
5. GALLONS DELIVERED TAX
054 PROPANE (LPG)
130 JET FUEL
227 LS/DIESEL - DYED
COLLECTED
5X. GALLONS DELIVERED & PARTIALLY
065 GASOLINE
145 LS/KEROSENE – CLEAR
167 LS/DIESEL - CLEAR
TAXED
6. GALLONS DELIVERED IN GA. TO
124 GASOHOL
226 HS/DIESEL – DYED
224 COMPRESSED NATURAL GAS (CNG)
LICENSED MOTOR FUEL
125 AVIATION GASOLINE
284 BIO DIESEL (CLEAR)
225 LIQUID NATURAL GAS (LNG)
DISTRIBUTORS – TAX NOT
COLLECTED
123 ALCOHOL
_____________________ OTHER SPECIFY, SEE FTA PRODUCT CODE LIST
7. GALLONS EXPORTED TO STATE
________________
8.
GALLONS DELIVERED TO U.S.
GOV’T –TAX EXEMPT
9.
N/A
10.
GALLONS DELIVERED TO OTHER
EXEMPT ENTITIES
(4)
(1)
(2)
(5)
(7)
(8)
(9)
(12)
(3)
POINT OF
(6)
CARRIER
CARRIER
TERMINAL
PURCHASER’S
DATE
DOCUMENT
BILLED
MODE
SOLD TO
ORIGIN
DESTINATION
NAME
FEIN
CODE
FEIN
SHIPPED
NUMBER
GALLONS
(CITY)
(CITY, STATE)
TOTALS

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