Form 904 - Monthly Fuel Retailer Tax Return

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904
FORM
M
F
R
T
R
ONTHLY
UEL
ETAILER
AX
ETURN
NOTE: THIS REPORT SHOULD ONLY REFLECT NET GALLONS PURCHASED ON WHICH THE FUEL
EXCISE TAX HAS NOT BEEN CHARGED
TIN/SSN
: #
Check box if AMENDED and enter correct Month ended (below) being "amended"
Taxpayer Name
Reporting Period (Quarter)
ONTC
OFFICE USE
Mailing Address
License Number
ONLY
Check here if mailing address has changed.
1 . Form 905 (Total purchase on which tax has not been paid) . . . . . . . . . . . . . . . . . . . . . . . . . .
2. Tax Due (Line 1 x $0.18) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . =
3. Interest(s) - if applicable.
. . . +
[Calculate interest owed and enter amount - attach calculations]
4. Penalty(s) - if applicable.
. . . +
[Calculate interest owed and enter amount - attach calculations]
2, 3, and 4
5 . TOTAL TAX DUE (Add Lines
). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . =
under $10,000 make
over $10,000 must be wire transferred
For payments
Payments
check payable to the order of & mail to:
to the following account:
Office of the Navajo Tax Commission
The Navajo Nation
Check here if
Post Box 1903
Account Number: 4000901560
payment is made
Window Rock, Arizona 86515-1903
Wells Fargo Bank - Window Rock Branch
by wire transfer
Phone: (928) 871-6681
Window Rock, Arizona 86515
Amount
Fax: (928) 871-7608
Bank Routing Number: 091000019
$
I declare that the information contained in this document and any attachments thereto is true and correct to
the best of my knowledge and belief pursuant to all Navajo Nation laws and regulations.
x
(
)
/
/
Taxpayer or Duly Authorized Agent Signature
Print or Type Name
Telephone Number
Date
ONTC
FET - Form 904
Revised: 2/12/02

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