Form 573a - Marketer Schedule Of Fuel Sales

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MARKETER SCHEDULE OF FUEL SALES
ON INDIAN RESERVATIONS DEFINED BY 18 U.S.C. 1151 (a)
AND INDIAN COUNTRY DEFINED BY 18 U.S.C. 1151 (b) & (c)
Mail
Remittance Center
Refund
P.O. Box 5055
Form To:
Sioux Falls, SD 57117-5055
Report below the Total Gross Gallons Sold During Reporting Period for Highway or Aircraft Use (Do not include
gallons sold to the Federal Government, Licensed Indian Schools and Reefer Sales in the total).
Gasoline
Clear
Diesel
100% Ethyl
Alcohol
LPG
Clear
Soy Diesel
Avgas
Jet Fuel
100% Methyl
Alcohol
CNG
Other
TOTAL
GALLONS
I declare and affirm under the penalty of perjury that this report has been examined by me, and to the best of my knowledge and belief is
in all things true and correct.
Signature
Title
Date
DOR/DMV FORM 573A (7/2009)

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