Form Dr-309634 Sample - Local Government User Of Diesel Fuel Tax Return - 2015
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800001 0000001
DR-309634
Local Government User of Diesel Fuel Tax Return
R. 01/14
Page 1
For Calendar Year:
2015
Rule 12B-5.150
Florida Administrative Code
Effective 01/14
Handwritten Example
Typed Example
0 1 2 3 4 5 6 7 8 9
0123456789
Use black ink.
IMPORTANT
Complete and return
coupon to the Department
of Revenue.
COMPLETE FORM DR-309634
BEFORE ENTERING INFORMATION
ON THE ATTACHED COUPON.
Mail the original of this form along with coupon
to the:
Florida Department of Revenue
5050 W Tennessee St
Tallahassee FL 32399-0165
Detach
Detach
here
here
Mail To:
Local Government User of Diesel Fuel Tax Return Coupon
DR-309634
Florida Department of Revenue
R. 01/14
For Calendar Year:
5050 W Tennessee St
2015
COMPLETE and MAIL with your RETURN/PAYMENT.
Tallahassee FL 32399-0165
Be sure to SIGN YOUR CHECK.
Florida Department of Revenue
FEIN
ENTER BUSINESS NAME:
US Dollars
Cents
AMOUNT DUE
,
,
FROM LINE 17
Name
IF CREDIT DUE ENTER 0
Address
City/St/ZIP
FOR COLLECTION
M M D D
Y
Y
PERIOD ENDING
DR-309634
Do Not Write in the Space Below.
9200 0 20159999 0094027034 8 3000000001 0000 2
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