STATE OF DELAWARE MOTOR FUEL TAX ADMINISTRATION MULTIPLE SCHEDULE OF RECEIPTS
COMPANY NAME: LICENSE NUMBER: FEIN: SCHEDULE NUMBER:
Original Schedule Amended Schedule Final Schedule
MONTH/YEAR
SCHEDULE NUMBER 1 2 3 4 Gallons received tax paid. Gallons received from licensed accounts, tax unpaid. Gallons imported from another state direct to customer. Gallons imported form another state into tax free storage. 1 Carrier Name 2 Carrier FEIN 3 Mode 124 Gasohol 079 E-85 (85% Ethanol) 125 Aviation Gasoline 167 Low Sulfur Diesel-Undyed 4 Point of Origin Dest. 5 Acquired From
PRODUCT TYPE 284 Pure Biodiesel (B100)-Undyed 290 Pure Biodiesel (B100)-Dyed 170 Biodiesel (B1-B99)-Undyed 171 Biodiesel (B1-B99)-Dyed 6 Delaware Distributor/ Supplier License # 7 Seller's FEIN 54 Propane 224 Compressed Natural Gas 227 Low Sulfur Diesel Fuel - Dyed ____ Other (see FTA product code list) 8 9 10 Gross Gallons
Date Received
Document Number
MSR-1 Revised 7/1/07
TOTAL