Form Pt-100 - Petroleum Business Tax Return
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1Department of Taxation and Finance
For office use only
PT-100
1115
Petroleum Business Tax Return
(11/15)
Tax Law – Articles 12-A and 13-A
Use this form to report transactions for the month of November 2015. This return must be filed by December 21, 2015.
Federal employer identification number (EIN)
Business telephone number
Change of business information -
You can update your address and
(
)
other business information by
Legal name
visiting our Web site (see Need
help? in Form PT-100-I). Select
the option to change your address
DBA
for further instructions. For
more information, see Changes
in business information in the
Street
instructions.
City, state, ZIP code
Read Form PT-100-I, Instructions for Form PT-100, carefully. Keep a copy of this completed form for your records.
Payment – Attach your check or money order payable in U.S. funds to: Commissioner of Taxation and Finance.
Payment enclosed
Mail to: NYS TAX DEPARTMENT, PO BOX 1833, ALBANY NY 12201-1833
Type of filer
– Mark an X in all boxes that apply. You must submit the appropriate attachments for each box marked.
Totals
Motor fuel
(registered as a distributor of motor fuel or as a liquefied petroleum gas fuel permittee)
1
..................................................................................................................
1
(from Form PT-101, line 29)
Diesel motor fuel
(registered as a distributor of diesel motor fuel)
2
..................................................................................................................
2
(from Form PT-102, line 48)
(registered as a residual petroleum product business)
Residuals
3
..................................................................................................................
3
(from Form PT-103, line 27)
Tax on kero-jet fuel
(registered as a distributor of diesel motor fuel, distributor of kero-jet fuel only,
4
or as an aviation fuel business) (from Form PT-104, line 17) ...............................................................................
4
(
)
Electric corporations
5
.......................................................................
(from Form PT-105, line 3)
5
Retailers of non-highway diesel motor fuel only
(registered as a retailer of non-highway
6
diesel motor fuel only) (from Form PT-106, line 28)
..................................................................................
6
7 Subtotal of tax due
.................................................................................................
7
(add lines 1 through 6)
8 Credits from prior month’s return .............................................................................................................
8
9 Tax due after credits
........................................................................................
9
(subtract line 8 from line 7)
10 Refund/reimbursement from Form PT-100-B
....................................................... 10
(attach Form PT-100-B)
11 Balance due
... 11
(add lines 9 and 10; if an overpayment, enter 0 and enter the overpayment amount on line 17 below)
12 Current period electronic funds transfer or certified check payment already made
(mark appropriate box)
A
- based on actual tax due for the period November 1 through November 22, 2015
or
- based on last year’s comparable period (November 2014) .................................................. 12
E
13 Net balance due
........................................................................................... 13
(subtract line 12 from line 11)
14 Penalties
....................................................................................................................... 14
(see instructions)
15 Interest
.......................................................................................................................... 15
(see instructions)
16 Total amount due
............................................................................................... 16
(add lines 13, 14, and 15)
17 Overpayment
........................................................................... 17
(see line 11)
18 Amount to be credited to next month’s return ........................................... 18
19 Amount to be refunded
................................................... 19
(see instructions)
I am a sales tax exempt organization and not subject to the Article 13-A tax on petroleum businesses
.
(see instructions)
My exemption number is
.
I certify that this business is duly licensed or registered to deal in each of the products that are being reported and that this return,
including any accompanying riders, is to the best of my knowledge and belief true, correct, and complete.
Signature of authorized person
Official title
Authorized
E-mail address of authorized person
Date
person
Firm’s name
Firm’s EIN
Preparer’s PTIN or SSN
(or yours if self-employed)
Paid
preparer
Signature of individual preparing this return
Address
City
State
ZIP code
use
only
E-mail address of individual preparing this return
Preparer’s NYTPRIN
Date
(see instr.)
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