STATE OF ARKANSAS
COMPANY NAME
MOTOR FUEL TAX SCHEDULE OF RECEIPTS
LICENSE NUMBER FEIN MONTH / YEAR
FORM R
SCHEDULE TYPE - Circle only one number per schedule 1. Gallons Received Tax Paid. 2. Gallons Received in ARKANSAS Tax Unpaid. 3. Gallons Imported from another State.
COLS. 2, 10, 11 NOT USED IN ARKANSAS
PRODUCT TYPE - Circle only one number per schedule 65 - GASOLINE 124 - GASOLINE 125 - AVIATION GAS (4) POINT OF (5) ACQUIRED FROM DESTINATION 130 - JET FUEL 142 - KEROSENE 160 - DIESEL UNDYDED (6) SELLER'S FEIN / SSN (7) DATE RECEIVED 228 - DIESEL DYE-ADDED 54 - PROPANE ____ - OTHER (8) DOCUMENT NUMBER (9) NET GALLONS
(1) CARRIER NAME
(3) MODE ORGIN
PLEASE FOOT EACH PAGE SEPARATELY AND CARRY TOTAL TO LAST PAGE OF SCHEDULE.
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