Form Ga-1a - Motor Fuel Tax, Multiple Schedule Of Gasoline Receipts

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GA-1A

State of New Jersey

2-98, R-2

DIVISION OF TAXATION

SCHEDULE * _____________

MOTOR FUEL TAX

PRODUCT CODE ** _____________

MULTIPLE SCHEDULE OF GASOLINE RECEIPTS

(Use a separate form for each schedule and product)

FID No. _______________________________________

Company Name _____________________________________________________________________________ Month of __________________________________ 20 ______

* TYPE OF SCHEDULE

3. Gallons Imported from Another State Direct to

** PRODUCT CODE (PC) - TYPE OF PRODUCT

Customers

1. Gallons Received - Tax Paid

A - Gasoline

D - Quantity Extender

4. GAllons Imported from Another State into Tax

2. Gallons Received from Licensed Motor Fuel

B - Alcohol/Gasoline

E - Other (Identify)

Free Storage

Distributors & Jobbers - Tax Unpaid

C - Aviation Gasoline

5. Other Receipts

(1)

(2)

(3)

(4)

(5)

(6)

(7)

Seller

Date

Invoice or

Acquired From

Federal ID No.

MM / DD / YY

Document No.

Gallons

Name of Carrier

Origin

Destination

All Columns must be completed for each transaction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

TOTAL

THIS FORM MAY BE REPRODUCED