Form R - Arkansas Motor Fuel Tax Schedule Of Receipts
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1MOTOR FUEL TAX SCHEDULE OF RECEIPTS
STATE OF
FORM
ARKANSAS
R
COMPANY NAME
LICENSE NUMBER
FEIN
MONTH / YEAR
SCHEDULE TYPE - Circle only one number per schedule
PRODUCT TYPE - Circle only one number per schedule
1. Gallons Received Tax Paid.
65 - GASOLINE
130 - JET FUEL
228 - DIESEL DYE-ADDED
2. Gallons Received in ARKANSAS Tax Unpaid.
124 - GASOLINE
142 - KEROSENE
54 - PROPANE
3. Gallons Imported from another State.
125 - AVIATION GAS
160 - DIESEL UNDYDED
____ - OTHER
COLS. 2, 10, 11 NOT USED IN ARKANSAS
(1)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
POINT OF
ACQUIRED
SELLER'S
DATE
DOCUMENT
NET
CARRIER NAME
MODE
ORGIN
DESTINATION
FROM
FEIN / SSN
RECEIVED
NUMBER
GALLONS
TOTAL
PLEASE FOOT EACH PAGE SEPARATELY AND CARRY TOTAL TO LAST PAGE OF SCHEDULE.
Page ____ of ____
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