Schedule Of Disbursements - Seal Of The State Of Indiana
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1
2Schedules 5 through 10
SF# 49082
Schedule of Disbursements
(R3 \ 12-08)
License number
Company name
Fein
Month / Year
□
You may photocopy this blank schedule for future filings. Attach ad-
Schedule Type (Check One)
7A Special Fuel Gallons Sold to Unlicensed exporters for
□
.
export to State of (Dest. State Tax Collected)
ditional sheets if necessary
5
Gallons Delivered, Tax Collected and Gallons Blended or
(Must be filed in duplicate)
Dyed Fuel Used
□
□
Please see the product code matrix on the Web site at
7B Special Fuel Gallons Sold to Licensed exporters for export t
6
Gallons Delivered Via Rail, Pipeline or Vessel to Licensed
State of (Must be filed in duplicate)
Suppliers, Tax not Collected (Special Fuel)
□
□
8
Gallons of Undyed Special Fuel, Gasoline and Kerosene sold
6D Gallons Sold to Licensed Distributors, Tax not Collected
to the U.S. Government Tax exempt
(Gasoline Only)
□
□
8K Kerosene Sales (SF-900 information only)
6X Gallons Disbursed on exchange
□
□
Gallons exported to State of (Must be filed in duplicate)
10
Gallons Sold of Tax exempt Dyed Fuel
7
□
10A Gallons Delivered to Marina Fuel Dealers
□
10B Gallons Delivered to Aviation Fuel Dealers
(3)
Sales / Delivery information
(11)
Transporter information
(4)
(5)
(10)
(12)
Point of
(8)
Gross
Billed
(1)
(2)
(6)
(7)
(9)
net
Date
Gallons
Gallons
name
Sold
Fein
Gallons
Fein
Document
Origin
Dest.
Term.
Mode
Sent
To
number
(State)
(State)
Code
Total
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