Form R-5290 - Motor Fuel Tax Multiple Schedule Of Disbursements - Louisiana Department Of Revenue

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Louisiana Department of Revenue
R-5290 (7/04)
Motor Fuel Tax Multiple Schedule of Disbursements
Company name __________________________ Account number ____________ Schedule number ____________ Month of ____________
Year ______
Type of schedule
PC –
Type of product*
G –
Kerosene
6 Gallons delivered to U.S. government tax exempt
A
–
Gasoline
H
–
Other (Identify.)
7 Gallons delivered to bonded wholesalers or jobbers
B
–
Alcohol
8 Gallons exported to State of___________________________ by common/contract carrier
C
–
Gasohol
9 Gallons sold within the bulk transfer/terminal system
D
–
Aviation gasoline
10 Gallons delivered tax collected including own use
E
–
Aviation jet fuel
F
–
Diesel
1
2
3
4
5
6
7
Point of
Bill of
Name of
Sold
Invoice
lading
Date
carrier
Origin
Destination
to
number
number
Gallons
Total
*Note: Use a separate schedule for each product.

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