Receipts Schedule - Distributor Fuel Tax Return - Tennessee Department Of Revenue

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Receipts Schedule - Distributor Fuel Tax Return (Attach to PET 350)
Company Name:
FEIN:
Account Number:
Month of (MM-YY):
Tennessee Department of Revenue
Product Type (Circle One)
65 GASOLINE
122 BLENDING COMPONENTS (TRANSMIX)
123 ALCOHOL
SCHEDULE TYPE
_______________
124 GASOHOL
1 . GALLONS RECEIVED TAX PAID
125 AVIATION GASOLINE
2. GALLONS RECEIVED FROM LICENSED SUPPLIER OR TN REFINERY TAX UNPAID
130 JET FUEL
2C. GALLONS RECEIVED IMPORTED (TAX UNPAID)
142 KEROSENE
3. GALLONS IMPORTED FROM ANOTHER STATE DIRECT TO CUSTOMER
160 UNDYED DIESEL
4. GALLONS IMPORTED FROM ANOTHER STATE INTO TAX-FREE STORAGE
226 DIESEL (HIGH SULFUR DYED)
4B. GALLONS IMPORTED DIRECTLY INTO REFINERY STORAGE (TN REFINERY ONLY)
227 DIESEL (LOW SULFUR DYED)
____ OTHER (SEE ITA PRODUCT CODE LIST)
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
( 1 1 )
NAME
CARRIER
POINT OF
ACQUIRED
SELLER'S
RECEIVED
DOCUMENT
NET
GROSS
B I L L E D
CARRIER
FEIN
MODE
ORIGIN
DESTINATION
FROM
FEIN
DATE
NUMBER
GALLONS
GALLONS
GALLONS
PAGE __________ OF __________
TOTAL
RV-F1400601

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