Form 72a161 - Monthly Report For A Liquefied Petroleum Gas Dealer
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272A161 (7-07)
FOR DEPARTMENT USE ONLY
Commonwealth of Kentucky
MONTHLY REPORT
DEPARTMENT OF REVENUE
/
5 6
/
/
__ __ __ __ __ __
__ __
__ __
__ __
Account Number
Tax
Mo.
Yr.
LIQUEFIED PETROLEUM GAS DEALER
➤ See Instructions on Reverse
Name and Address of Dealer
License Number
Federal
Employer ID Number __ __ – __ __ __ __ __ __ __
Report for
(MM)/(YY)
Check Here if EFT Payment
–
Telephone Number (
)
Contact Person
TAX COMPUTATION
1. Taxable gallons (Form 72A178) (Schedule 5) ..............................................................................................
2. Tax-exempt gallons (Form 72A178) (Schedule 10) .....................................................................................
3. Total gallons of liquefied petroleum gas motor fuel (total line 1 plus line 2) ..............................................
4. Gross tax liability (line 1 times tax rate per gallon) .................................................................................. $
5. Less: Allowance for handling and reporting (1% of line 4) ..................................................................... $ (
)
6. Net Tax Due (line 4 minus line 5) ............................................................................................................ $
7. Credit(s) for previous payments and other authorized credits (attach a copy of authorization) .............. $ (
)
8. Total tax due (overpayment) (line 6 minus line 7) ................................................................................... $
IMPORTANT NOTICE
Make check payable to: KENTUCKY STATE TREASURER
Mail report and check to: KENTUCKY DEPARTMENT OF REVENUE, FRANKFORT, KENTUCKY 40619
I, the undersigned, a principal officer of the above-named licensee, have examined this report and it is, to the best of my knowledge
and belief, a true, correct and complete report.
Signature
Title
Date
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