| NAME AND ADDRESS | DEALER MONTHLY FUEL REPORT | Wyoming Department of Transportation | |||
| Fuel Tax Administration | |||||
| 5300 Bishop Boulevard | |||||
| Cheyenne, WY 82009-3340 | |||||
| REPORT MONTH:____________________ | Phone: 307-777-4828 Fax: 307-777-4769 | ||||
| For Office Use Only: | |||||
| FEIN:_________________________________ | |||||
| Check here if new mailing address. | |||||
| Check here if this is an amended report. | |||||
| Check this box to cancel. Attach your license and indicate effective Date:__________________________ | |||||
| List Below the total gallons you PURCHASED from each Supplier/Distributor/Importer | |||||
| Supplier, Distributor/ Importer Name | FEIN | Gasoline | Gasohol | Undyed Diesel (includes Kerosene and Jet Fuel) | Dyed Diesel (includes dyed Kerosene) |
| Total Gallons of each FUEL Sold in this Month | |||||
| I DO HEREBY CERTIFY UNDER PENALTY OF PERJURY THAT THE ABOVE IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. | |||||
| Signature | Date | ||||
| Printed Name | Phone Number | Title | |||
| DLR 201307 |