Form Mfd-04 - State Of Georgia Computation Of Prepaid State Tax On Motor Fuel Sales & Use Page 8
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Form MFD-04 (Rev. 6/13)
GENERAL INSTRUCTIONS FOR SCHEDULES
ALL RECEIPTS AND DISBURSEMENTS OF MOTOR FUEL
MUST BE ACCOUNTED FOR ON THE APPROPRIATE SCHEDULE
Distributor’s Name/License Number/---------------------------
Reporting Company’s name, license number and report month.
Report Month
Schedule Type -----------------------------------------------------
Enter one of the numbers corresponding to the schedule type
reflected on either the Receipts or Disbursements Schedule.
Carrier Name -------------------------------------------------------
Enter name of carrier.
Carrier FEIN -------------------------------------------------------
Enter carrier’s FEIN (Federal Employer Identification No.).
Mode ----------------------------------------------------------------
Enter one of the following letters reflecting the mode of
transportation:
J-Truck PL- Pipeline B-Barge R-Railroad or O- Other (specify)
Point of Origin------------------------------------------------------
Enter the location (city and state) from which product was
transported.
Point of Destination------------------------------------------------
Enter the location (city and state) from which product was
delivered.
Acquired from/Sold To--------------------------------------------
Enter the name of the company.
Supplier/Purchaser License---------------------------------------
Enter the purchaser’s FEIN on Schedule 5 and/or 5X. Enter the
supplier’s license number on the schedule of receipts.
Product Code--------------------------------------------------------
Enter the number that corresponds to the type product received or
sold.
You may combine several product codes as indicated on the form.
You must subtotal gallons by reported product type.
Gallons-----------------------------------------------------------------
Enter your billed gallons. For receipt schedules report the gallons
invoiced to you by the supplier. For disbursement schedules report
the gallons you invoiced to your customer.
Should you have any questions regarding the preparation and filing requirements of the Motor Fuel Tax Report and Schedules you
may call us at (404) 417-6710.
COMPANY NAME AND/OR ADDRESS CHANGES?
Please make required changes on the next page and forward to the indicated address.
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