Form Rmft-29-A - Schedule M - Gasoline

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Illinois Department of Revenue
Page ____ of ____
Schedule M — Gasoline
MFT, UST, and EIF
Products Used for Blending
Attach to Form RMFT-5
Step 1: Complete the following information
Do not report special fuel (such as diesel) on this schedule.
______________________________________________
Company name
Use Schedule M-Special Fuels.
______________________________________________
Your license number
Reporting period __ __/__ __ __ __
Month
Year
Step 2: Report your blending activity
(If column 2c, 3c, or 4b is used, write the exact name of the product on the line provided.)
1
2
3
4
Primary product gallons
Blending agent gallons
Total end product gallons
(Report one product type per page.)
a
b
c
a
b
c
a
b
Blended date
Other (Identify)
Other (Identify)
Other (Identify)
Gasoline
Ethanol
_______________
Gasoline
Ethanol
_______________
Gasohol
_______________
(month, day, year)
1
_ _/_ _/_ _ _ _ ____________________________________________________________________________________________________________________________________
2
_ _/_ _/_ _ _ _ ____________________________________________________________________________________________________________________________________
3
_ _/_ _/_ _ _ _ ____________________________________________________________________________________________________________________________________
4
_ _/_ _/_ _ _ _ ____________________________________________________________________________________________________________________________________
5
_ _/_ _/_ _ _ _ ____________________________________________________________________________________________________________________________________
6
_ _/_ _/_ _ _ _ ____________________________________________________________________________________________________________________________________
7
_ _/_ _/_ _ _ _ ____________________________________________________________________________________________________________________________________
8
_ _/_ _/_ _ _ _ ____________________________________________________________________________________________________________________________________
9
_ _/_ _/_ _ _ _ ____________________________________________________________________________________________________________________________________
10
_ _/_ _/_ _ _ _ ____________________________________________________________________________________________________________________________________
11
Add Lines
1 through 10.
____________________________________________________________________________________________________________________________________
12
See
instructions.
____________________________________________________________________________________________________________________________________
This form is authorized as outlined by the Motor Fuel Tax Law and the Environmental Impact Fee Law. Disclosure of this information is REQUIRED.
Failure to provide information could result in a penalty. This form has been approved by the Forms Management Center.
IL-492-4340
RMFT-29-A front (R-1/03)

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