DIE 201603

  NAME AND ADDRESS     WYOMING DISTRIBUTOR, IMPORTER, EXPORTER       Wyoming Department of Transportation
        MONTHLY TAX RETURN       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:  
  Include all 14 digits from WY Motor Fuel License Issued by FTA.       Cover:   Sch/EDI:  
  Check here if new mailing address.       Verify:   File:  
  Check here if this is an amended tax return. Attach corrected schedules & supporting documentation.       CC:      
  Check this box to cancel. Attach your license and indicate effective date __________________________.              
                 
    Uniform Schedule Gasoline Includes 054, 065, 124, 224 Blending Components Incl. Natural Gas 052, 055, 122, 123, 284, 290 Aviation Gasoline 125 Jet Fuel 130 Undyed Diesel Includes 142, 160, 170, 225 Dyed Diesel Includes 072, 171, 228
  Inventory and Receipts (schedule information)              
1 Actual metered/dipped beginning WY inventory (must agree with prior month's ending inventory)              
2 Total gross gallons purchased--TAX PAID 1A            
3 Total gross gallons purchased--TAX UNPAID 2B, 2C            
4 Total gross gallons purchased for export--TAX UNPAID 2, 2E            
5 Transfers (a minus from one product and a plus to the other product) See instructions for transfers.              
6 Total gross gallons available to distribute (Add Lines 1 through 5.)   0 0 0 0 0 0
  DISBURSEMENTS (schedule information)              
7 Total gross gallons sold 100% tax paid. Schedule 6B is for the Blending Components Only. 5, 6B            
8 Do Not use this Line              
9 Wyoming TAX-PAID gross gallons EXPORTED by you (destination state required on schedule). 7B            
10 Total gross gallons sold & subject to refund--(Add Lines 8 & 9.)   0   0 0 0 0
11 Total TAX-UNPAID gross gallons brokered or exported by you (destination state required on schedule). 6, 7            
12 Total gross gallons disbursed--(Add Lines 7, 10, and 11.)   0 0 0 0 0 0
13 Actual Gain/loss in monthly WY ending inventory   0 0 0 0 0 0
14 Actual metered/dipped WY ending inventory Do not report book inventory.              
  Note: Please use (parentheses) to indicate negative or refund              
                 
    For Office Use Only:            
                 
  Fuel Tax Computation   Gasoline Includes 054, 065, 124, 224 Blending Components Incl. Natural Gas 052, 055, 122, 123, 284, 290 Aviation Gasoline 125 Jet Fuel 130 Undyed Diesel Includes 142, 160, 170, 225 Dyed Diesel Includes 072, 171, 228
15 Total TAX UNPAID gross gallons purchased--Line 3   0   0 0 0 0
16 Motor fuel tax rate(s)   $0.23   $0.04 $0.04 $0.23  
17 Additional license tax (A.L.T.) tax rate   $0.01   $0.01 $0.01 $0.01 $0.01
18 Motor fuel taxes due--(Line 15 times Line 16)   $0.00   $0.00 $0.00 $0.00  
19 A.L.T. taxes due--(Line 15 times Line 17)   $0.00   $0.00 $0.00 $0.00 $0.00
20 Total Taxes Due--(Line 18 plus Line 19)   $0.00   $0.00 $0.00 $0.00 $0.00
21 Taxes paid and (subject to refund)--(Line 9 times Line 16)   $0.00   $0.00 $0.00 $0.00  
22 A.L.T. Tax paid and (subject to refund)--(Line 9 times Line 17)   $0.00   $0.00 $0.00 $0.00 $0.00
23 Authorized Credit or Billings. Contact Department for authorization to use these lines for transfers in inventory, diverted loads, excess tax collected, or bad debt loss. Attach billing/credit notice if applicable. Note: The tax due on blending components              
a used during the month should be reported on these lines, 23 for the motor fuel tax and 23a for the additional license tax.              
24 Shrinkage Credit: Total eligible gallons. See instructions to determine eligible gallons.              
a Total shrinkage motor fuel tax credit--(Line 24 times .01 times Line 16)   $0.00   $0.00 $0.00 $0.00  
b Total shrinkage additional license tax credit--(Line 24 times .01 times Line 17)   $0.00   $0.00 $0.00 $0.00 $0.00
25 Fuel taxes due or (subject to refund)--(Line 20 through 23a plus 24a and 24b)   $0.00   $0.00 $0.00 $0.00 $0.00
              Total tax due or (to be refunded) $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)  
              Balance due or (to be refunded) $0.00
  COMPANY NAME FEIN   REPORT PERIOD          
                 
  PRINT NAME OF PREPARER PHONE NUMBER     AUTHORIZED SIGNATURE   TITLE   DATE
                 
  Note: Please use (parentheses) to indicate negative or refund              
                 


Receipts

                             
  SCHEDULE OF RECEIPTS   Company Name       FEIN Schedule Type Month/Year      
                   
                             
  SCHEDULE TYPE:                          
1A Gallons Received, Originating State Tax Paid                          
2 Gallons Received from Motor Fuel Licensee Tax Unpaid             PRODUCT TYPE - (CIRCLE ONE)            
2B Gallons Received Tax Unpaid, Blendable Stock           052 Ethane 123 Alcohol - Ethanol/Methanol            
2C Gallons Received, Imported, Tax Unpaid           054 Propane 124 Gasohol 170 Biodiesel - Undyed (not B100)   284 Undyed Biodiesel (B100)     For office Use Only:
2E Gallons Received for Export           055 Butane 125 Av-Gas 171 Biodiesel - Dyed (not B100)   290 Dyed Biodiesel (B100)      
              O65 Gasoline 130 Jet Fuel 224 Compressed Natural Gas          
              072 Dyed Kerosene 142 Undyed Kerosene 225 Liquid Natual Gas          
              122 Blending Components 160 Undyed Diesel 228 Dyed Diesel          
                             
  (1) (2) (3) (4)   (5) (6) (7) (8) (9) (10) (11)    
        POINT OF                  
  Carrier Name Carrier FEIN MODE ORIGIN Terminal code or WY city, town, or county if pulled from other than a terminal rack 2C cannot be WY DESTINATION WY city, town, county; Terminal code if title transfers at rack Acquired From Seller's FEIN Date Received Document Number Net Gallons Gross Gallons Billed Gallons    
                             
  DIE (201603)               Total 0 0 0    


Disbursements

  SCHEDULE OF DISBURSEMENTS   Company Name       FEIN Schedule Type Month/Year      
                   
                             
  SCHEDULE TYPE:                          
5 Gallons Delivered Tax Collected             PRODUCT TYPE - (CIRCLE ONE)            
6 Gallons Delivered to Licensed Motor Fuel Licensees--tax not collected           052 Ethane 123 Alcohol - Ethanol/Methanol            
6B Gallons Sold Tax-exempt, Customer is a Licensed Blender           054 Propane 124 Gasohol 170 Biodiesel - Undyed (not B100)   284 Undyed Biodiesel (B100)      
7 Gallons Exported to State of _____________________           055 Butane 125 Av-Gas 171 Biodiesel - Dyed (not B100)   290 Dyed Biodiesel (B100)     For Office Use Only:
7B Gallons Sold for Export, Originating State Tax Paid           O65 Gasoline 130 Jet Fuel 224 Compressed Natural Gas          
              072 Dyed Kerosene 142 Undyed Kerosene 225 Liquid Natual Gas          
              122 Blending Components 160 Undyed Diesel 228 Dyed Diesel          
  (1) (2) (3)   (4) (5) (6) (7) (8) (9) (10) (11)    
        POINT OF                  
  Carrier Name Carrier FEIN MODE ORIGIN Terminal code or WY code if pulled from other than a terminal rack DESTINATION WY city, town, co. or Term code if title transfers at rack 7 & 7B must be state other than WY Sold To Purchaser's FEIN Date Sold Document Number Net Gallons Gross Gallons Billed Gallons    
                             
                  TOTAL 0 0 0    
                             
  DIE (201603)                          


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