Form 82-053 - Retailers Fuel Gallons Annual Report

Iowa Department of Revenue

Retailers Fuel Gallons Annual Report

https://tax.iowa.gov

Signature Required

Period: Jan. 1, 2014, through Dec. 31, 2014

I, the undersigned, declare under penalty of perjury that

Due Date: February 2, 2015.

I have examined this report, including all accompanying

Iowa License No: ______________________________

documentation, and to the best of my knowledge and

belief, it is a true, accurate and complete statement.

Signature: __________________________________

Date: ______________________________________

Print Name: _________________________________

Title: ______________________________________

Phone Number: ______________________________

County Name: ________________________________

E-mail Address: ______________________________

SSN: _______________________________________

Mail To: Iowa Department of Revenue

FEIN: _______________________________________

PO Box 10471, Des Moines, Iowa 50306-0471

Questions? Call 515-281-3114 or 1-800-367-3388

Iowa Sales Tax Permit No: ______________________

E-mail idr@iowa.gov

(for this location)

Round to the nearest whole gallon.

File a separate report for each retail location.

If you do not sell motor fuel at retail, please return the

Report gross gallons for each type of fuel sold for final

form with zeros in the gallons column.

consumption.

Complete for all types of fuel sold:

Type of Fuel

Gross Gallons

(round to the nearest whole gallon)

Part 1

Gasoline (non-ethanol) Gallons ................................................. 1. _____________________________

Gasoline Blend (10% - 14% ethanol = E10) .............................. 2. _____________________________

Gasoline Blend (15% - 69% ethanol = E15/E20) ....................... 3. _____________________________

Gasoline Blend (70% - 85% ethanol = E85) .............................. 4. _____________________________

Diesel and Biodiesel Gallons

Diesel Clear Gallons ............................................................... 5. _____________________________

Diesel Dyed Gallons ............................................................... 6. _____________________________

Total Gross Gallons For All Fuel Types

(add lines 1 thru 6) ..................................................................... 7. _____________________________

Part 2

Biodiesel Sales

All locations must complete this section and report biodiesel blends (2% to 99.8%). If you do not sell biodiesel at retail,

please return the form with zeros in the gallons column on lines 8, 9, 10. Any gallons reported on line 8 or 9 should

also be included above on line 5 or 6.

Type of Biodiesel

Gross Gallons

(round to the nearest whole gallon)

Clear B2 ................................... 8a ____________________

Clear B5 ................................... 8b ____________________

Clear B10 ................................. 8c ____________________

Clear B20 ................................. 8d ____________________

Clear B_____ ............................ 8e ____________________

Clear Biodiesel Subtotal

(add lines 8a thru 8e). ............................................................. 8. _____________________________

Dyed B2 ................................... 9a ____________________

Dyed B5 ................................... 9b ____________________

Dyed B10 ................................. 9c ____________________

Dyed B20 ................................. 9d ____________________

Dyed B_____ ........................... 9e ____________________

Dyed Biodiesel Subtotal

(add lines 9a thru 9e) .............................................................. 9. _____________________________

Total Biodiesel Gallons Sold

(add lines 8 and 9) ................................................................... 10. _____________________________

82-053a (11/26/14)

Form 82-053 - Retailers Fuel Gallons Annual Report - 2014

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