2017 Form 5083, Page 2
Taxpayer’s Business Name
Business Account Number
10. PuRCHaSed FoR ReSale
C:
d:
R = Purchased for
e:
a:
B:
Gasoline gallons purchased
Retail/Wholesale, or
Diesel gallons purchased for
Supplier Name
Supplier FEIN
for the tax period being
O = Purchased for
the tax period being reported
reported
Out-of-State Sale
11. Total columns D and E.......................................................................................... 11.
12. Applicable prepaid tax rate ................................................................................... 12.
XXXXX
13. Multiply line 11D by line 12D and carry to line 2a on page 1 of this form ............. 13.
14. Multiply line 11E by line 12E and carry to line 2b on page 1 of this form .............................................................
14.
15. Sold To mICHIGan WHoleSaleR oR To mICHIGan ReTaIleR
C:
D:
A:
B:
Gasoline gallons sold to
Diesel gallons sold to
Customer Name
Customer FEIN
customer for the tax period
customer for the tax period
being reported
being reported
16. Total columns C and D ......................................................................................... 16.
17. Applicable prepaid tax ate .................................................................................... 17.
XXXXX
18. Multiply line 16C by line 17C and carry to line 6a on page 1 of this form ............. 18.
19. Multiply line 16D by line 17D and carry to line 6b on page 1 of this form .............................................................
19.