Form 72a138 - Licensed Special Fuel Dealer'S Monthly Report

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72A138 (7-07)

FOR DEPARTMENT USE ONLY

LICENSED

Commonwealth of Kentucky

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5 5

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SPECIAL FUEL DEALER’S

DEPARTMENT OF REVENUE

Account Number

Tax

Mo.

Yr.

MONTHLY REPORT

Name and Address of Dealer

Check here for address change

Special Fuel Dealer’s Number FL __ __ __ __ __

Federal Employer ID Number __ __ – __ __ __ __ __ __ __

Report for (mm/yy) __ __ / __ __ __ __

(

)

Telephone Number ___________________________________

Check Here if EFT Payment

(

)

Fax Number ________________________________________

Contact Person

PART I—Computation of Special Fuel Subject to Tax

Attach

COLUMN A

COLUMN B

COLUMN C

RECEIPTS

Schedule

In gallons

1. Special fuel purchased in Kentucky (Form 72A179) ..............................

2. a. Special fuel sold for import into Kentucky

(Supplier’s Report) (Form 72A178) .................................................

b. Special fuel imported into Kentucky from other

states (Form 72A179) .......................................................................

c. Total imports (add line 2a and line 2b) ..............................................

3. Special fuel disbursements from terminal storage (Form 72A179) .........

4. Kerosene blended with other special fuel and all other

receipts (Form 72A179) .........................................................................

5. Total special fuel received (add lines 1, 2c, 3 and 4) ............................

DEDUCTIONS

6. Special fuel exported from Kentucky (Form 72A178) ...........................

7. Special fuel sold to other Kentucky licensed dealers (Form 72A178) ....

8. Special fuel lost through accountable losses (Approved Form 72A078) .

9. Special fuel sold to railroad companies for nonhighway

purposes (Form 72A178) .......................................................................

10Y

10. Special fuel sold to U.S. government (Form 72A178) ...........................

11. Special fuel used by licensed dealer for nonhighway purposes related to the distribution of

special fuel to others ................................................................................................................................................

12. Total special fuel deductions (add lines 6 through 11) ...........................................................................................................................

13. Total special fuel gallons subject to tax (line 5 minus line 12) .............................................................................................................

PART II—Tax Computation

14. Gross tax liability (line 13 times tax rate) ................................................................................................................................

15. Tax rate adjustment for special fuel gallons inventory held in wholesale bulk storage on the last day of the period

(rate increase (decrease) _______ times ______ gallons) .......................................................................................................

16. Tax due after the tax rate adjustment (line 14 plus line 15) ......................................................................................................

17. Nonhighway dealer credits (Form 72A178)

Sales of special fuel for agricultural purposes

(gallons on Sch. 10I ________ times tax rate) .........................................................

)

b. Sales of special fuel for residential heating purposes

(gallons on Sch. 10J ________ times tax rate) ........................................................

)

Sales of special fuel to state or local government agencies

(gallons on Sch. 9 ________ times tax rate) ............................................................

)

d. Sales of special fuel to nonprofit religious, charitable or educational organizations

(gallons on Sch. 10G ________ times tax rate) .......................................................

)

Sales of special fuel for commercial use

(gallons on Sch. 10A ________ times tax rate) .......................................................

)

18.

Total nonhighway dealer credits (add lines 17a, 17b, 17c, 17d and 17e) ................................................................................

)

19.

Tax due after credits (line 16 minus line 18) ...........................................................................................................................

20.

Dealer compensation allowance (2¼% of line 19 if report and payment are timely submitted) .............................................

)

21.

Net tax due after allowable compensation (line 19 minus line 20) .........................................................................................

)

22.

Credit(s) for previous payments and other authorized credits (attach copy of authorization) .................................................

)

23.

Total tax due (overpayment) (line 21 minus line 22) .............................................................................................................

PART III—Statistical Gallons

Special fuel gallons imported into Kentucky (Kentucky tax paid to supplier) Form 72A179 (Schedule 1).

Make check payable to: KENTUCKY STATE TREASURER.

IMPORTANT NOTICE

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.

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Signature

Print Name

Title

Date