Petroleum Environmental Fee Report Form - Arkansas
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1
2DEPARTMENT OF FINANCE & ADMINISTRATION
Motor Fuel Tax Section
P. O. Box 1752 / Little Rock, AR 72203-1752 / Phone (501) 682-4800 FAX: (501) 682-5599
Petroleum Environmental Fee Report
AMENDED REPORT
FINAL REPORT
Check Here if Filing
Check Here if Filing
NAME
ACCOUNT NUMBER
0
0
0
0
P O BOX
FEIN
STREET
YEAR
MONTH
NUMERICAL
20
REPORT MONTH
CITY STATE ZIP
PHONE NUMBER
(
)
MOTOR FUEL FIRST RECEIVER OR IMPORTER
1.
Total Motor Fuel Received in Arkansas...............................................................................................
2.
Exported from Arkansas. ......................................................................................................................
3.
Tax Paid Purchases. ..............................................................................................................................
4.
Sales to First Receiver. .........................................................................................................................
5.
Total Lines 2, 3 and 4.............................................................................................................................
6.
Gallons Subject to Fee. (Line 1 minus Line 5).......................................................................................
7.
Total Motor Fuel Fee Due. (Line 6 x .003). ............................................................................................
DISTILLATE SPECIAL FUEL FIRST RECEIVER OR IMPORTER
8.
Total Distillate Special Fuel Received in Arkansas. ...........................................................................
9.
Exported from Arkansas. ......................................................................................................................
10. Sales to First Receiver. .........................................................................................................................
11. Tax Paid Purchases. .............................................................................................................................
12. Total Lines 9, 10 and 11.........................................................................................................................
13. Gallons Subject to Fee. (Line 8 minus Line 12). ...................................................................................
14. Total Distillate Special Fuel Fee Due. (Line 13 x .003). .......................................................................
COMPUTATION OF FEE
15. TOTAL PETROLEUM ENVIRONMENTAL FEE DUE (Add Line 7 and Line 14)....................................
The Undersigned hereby declare under penalties of law that the information provided is true and correct the best of my knowledge.
Signature
________________________________________
Date ____________________________
AMFT-56(A) R 10/05
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