Form 72a155 - Report Of Special Fuels Exported Or Sold For Export - Kentucky Department Of Revenue

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72A155 (10-06)
REPORT OF SPECIAL FUELS
Commonwealth of Kentucky
Exported to the State of
DEPARTMENT OF REVENUE
EXPORTED OR SOLD FOR EXPORT
_______________________
Name and Address of Dealer
INSTRUCTIONS: This report must be completed by all licensed special
fuels dealers who have exported special fuels or sold such fuels for export
Report for Month of___________________ , 20____
into another state. Gallons shipped must be reported using the same
measuring method used to report receipts. Use a separate line for each
shipment. File a separate report for each state. Complete this report in
Date Report Prepared__________________ , 20____
duplicate and attach both copies to Form 72A138.
Truck No.
Name and Address
Invoice
Date of
Gallons
Carrier
Origin
Destination
Car Initial and No.
of Consignee
Number
Shipment
Shipped
Barge No.
TOTAL*
*Total exports must equal line 6, Form 72A138.

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