Form Dr-904 Draft - Pollutants Tax Return - 2018 printable pdf download

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DR-904

Mail To:

Pollutants Tax Return

R. 01/15

Florida Department of Revenue

5050 W. Tennessee Street

2018

For Calendar Year:

Rule 12B-5.150

Tallahassee, Florida 32399-0165

Florida Administrative Code

Effective 01/15

DOR USE ONLY

POSTMARK OR HAND DELIVERY DATE

920002018999900340270314300000000100002

Check here if amending return

License Number:

Name

FEIN:

Address

City/St/ZIP

Collection Period Ending:

Use black ink.

Handwritten Example

Typed Example

0 1 2 3 4 5 6 7 8 9

0123456789

Return Due By

Late After

Complete Reverse Side of Return First

34.

Total tax due: (Enter the results of adding Columns 1,2,3, and 4, on Page 2, Line 33) ............

35.

Credit memos issued by the Department of Revenue: .............................................................

TOTAL DUE WITH RETURN CALCULATION

36.

Total tax due: ............................................................................................................................

37.

Penalty: .....................................................................................................................................

38.

Interest: .....................................................................................................................................

39.

Total due with return: ................................................................................................................

Important Notice: Crude oil produced at the well site and exported from that site by the producer exclusively by pipeline, truck, or

rail without intermediate stoppage or storage is the only pollutant allowed an export provision under the Coastal Protection Fund.

Under penalty of perjury, I declare that I have read this application and the facts stated in it are true.

__________________________________________________________________________________________________________________________________________________________

Signature of Offi cer/Owner

Title

Date

__________________________________________________________________________________________________________________________________________________________

Name of Preparer (Print)

Signature of Preparer

Telephone Number

FEIN