| Supplier Name and Address | SUPPLIER MONTHLY TAX RETURN | Wyoming Department of Transportation; Fuel Tax Administration | ||||||
| 5300 Bishop Boulevard; Cheyenne, WY 82009-3340 | ||||||||
| Phone: (307) 777-4826; Fax: (307) 777-4769 | ||||||||
| For Office Use Only: | ||||||||
| Check #: | ||||||||
| PMF: | ||||||||
| Wyoming Fuel Tax License No.: | Report Period: | Audit: | Avi: | |||||
| Check if here if new mailing address. | Cover: | Sch: | ||||||
| Check if here if an amended return. Attach corrected schedules & supporting documentation. | Verify: | File: | ||||||
| Check this box to cancel. Attach your license and indicate effective date ______________________ | ||||||||
| From Schedule | Gasoline Includes 054, 065, 124, 224 | Blending Components Incl. 052, 055, 122, 123, 284, 290 | Aviation Gasoline 125 | Jet Fuel 130 | Undyed Diesel 142, 160, 170, 225 | Dyed Diesel 072, 171, 228 | ||
| Receipts | ||||||||
| 1 | Total gallons received--Tax Paid | 1A | ||||||
| 2 | Total gallons received--Tax Unpaid | 2A,2B,3A | ||||||
| 2A | Transfers to minus from one product and a plus to the other product | |||||||
| Sales | ||||||||
| 3 | Total gallons removed--Tax Collected | 5 | ||||||
| 4 | Total gallons removed--Tax Exempt | 6A,6B, 6C,6D,7 | ||||||
| Fuel Tax Computation | ||||||||
| 5 | Wyoming fuel tax rate(s) | $0.23 | $0.04 | $0.04 | $0.23 | |||
| 6 | Wyoming A.L.T. tax rate | $0.01 | $0.01 | $0.01 | $0.01 | $0.01 | ||
| 7 | WY fuel taxes due--Include total gross gallons from Schedules 5. | $0.00 | $0.00 | $0.00 | $0.00 | |||
| 8 | A.L.T. taxes due--Include total gross gallons from Schedules 5 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||
| 9 | Total taxes due--(add lines 7 & 8) | $0.00 | $0.00 | $0.00 | $0.00 | |||
| 10 | Authorized Credit or Billing: (Contact department for authorization number for bad debt claim and form.) | |||||||
| 10a | Attach billing or credit notice issued by the department | |||||||
| 11 | Total taxes due--(add lines 9 through 10) | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||
| 11 | 12313 | |||||||
| Total Tax Due | $0.00 | |||||||
| I declare that everything contained on this return is a true and accurate statement. I am authorized to sign this return. | Penalty (10% of total tax due) | |||||||
| Interest (1% of total tax due times number of months late) | ||||||||
| Total amount remitted | $0.00 | |||||||
| Print Name of Preparer Phone Number | Authorized Signature | Title | Date | |||||
| SPL 201307 | ||||||||
| Supplier Name | Supplier FEIN | Month/Year | |||||||||||
| Schedule Type (circle one) | Product Type: (Circle One) | ||||||||||||
| 052 Ethane | 123 Alcohol -Ethanol /Methanol | ||||||||||||
| 054 Propane | 124 Gasohol | 171 Dyed Biodiesel Blend | |||||||||||
| 1A | Gallons received, originating state tax paid | 055 Butane | 125 Av Gas | 224 Compressed Natural Gas | |||||||||
| 2A | Gallons received from terminals or refineries, origin tax unpaid | 065 Gasoline | 130 Jet Fuel | 225 Liquid Natural Gas | |||||||||
| 2B | Gallons received tax unpaid, blendable stock | 072 Dyed Kerosene | 142 Undyed Kerosene | 228 Dyed Diesel | |||||||||
| 3A | Gallons imported from terminals/refineries in state of_____________________ | 122 Blending Components | 160 Undyed Diesel | 284 Undyed Biodiesel (B100) | |||||||||
| 170 Undyed Biodiesel Blend | 290 Dyed Biodiesel | ||||||||||||
| (1) | (2) | (3) | (4)4 | (5) | (6) | (7) | (8) | (9) | (10) | (11) | (12) | ||
| Carrier | Carrier | Mode | Point of | Terminal | Seller's | Seller's | Date | Document | Net | Gross | Billed | ||
| Name | FEIN | Origin | Dest. | Code | Name | FEIN | Shipped | Number | Gallons | Gallons | Gallons | ||
| Total | 0 | 0 | 0 | ||||||||||
| SPL 201307 | |||||||||||||
| Supplier Name | Supplier FEIN | Month/Year | |||||||||||
| Schedule Type (circle one) | |||||||||||||
| Product Type: (Circle One) | |||||||||||||
| 052 Ethane | 124 Gasohol | 171 Dyed Biodiesel Blend | |||||||||||
| 5 | Gallons removed tax collected | 054 Propane | 125 Av Gas | 224 Compressed Natural Gas | |||||||||
| 6A | Gallons sold tax-exempt, customer is a licensed exporter | 055 Butane | 130 Jet Fuel | 225 Liquid Natural Gas | |||||||||
| 6B | Gallons sold tax-exempt, blending components | 065 Gasoline | 142 Undyed Kerosene | 228 Dyed Diesel | |||||||||
| 6C | Gallons sold tax-exempt, customer is a licensed Importer | 072 Dyed Kerosene | 160 Undyed Diesel | 284 Undyed Biodiesel (B100) | |||||||||
| 6D | Gallons sold tax-exempt to other Supplier | 122 Blending Components | 170 Undyed Biodiesel Blend | 290 Dyed Biodiesel (B100) | |||||||||
| 7 | Gallons exported to state of ___________________ | 123 Alcohol -Ethanol /Methanol | |||||||||||
| (1) | (2) | (3) | (4)4 | (5) | (6) | (7) | (8) | (9) | (10) | (11) | (12) | ||
| Carrier | Carrier | Mode | Point of | Terminal | Purchaser's | Purchaser's | Date | Document | Net | Gross | Billed | ||
| Name | FEIN | Origin | Dest. | Code | Name | FEIN | Shipped | Number | Gallons | Gallons | Gallons | ||
| Total | 0 | 0 | 0 | ||||||||||
| SPL 201307 | |||||||||||||