Schedule Of Disbursements {Schedules 5-10}

State Form 49082 (R1/8-04) Schedules 5 through 10 Schedule of Disbursements Company Name License Number FEIN Product Code/Type (Check One) For Use with Reporting Special Fuel 142 Kerosene 161 Low Sulphur Diesel #1 - undyed 167 Low Sulphur Diesel #2 - undyed 226 High Sulphur Diesel - dye added 227 Low Sulphur Diesel - dye added 231 No. 1 Diesel - dye added 284 Biodiesel - undyed 290 Biodiesel - dye added OTH Other For Use with Reporting Gasoline/Oil Inspection 065 Gasoline 124 Gasohol 125 Aviation Gasoline 130 Jet FuelGasoline 142 Kerosene 150 #1 Fuel Oil - undyed 161 Low Sulphur Diesel #1 - undyed 231 No. 1 Diesel - dye added 241 Ethanol 243 Methanol 282 #1 High Sulphur Diesel - undyed OTH Other Month / Year You may photocopy this blank schedule for future filings. Attach additional sheets as necessary. Schedule Type (Check One) Gallons Delivered, Tax Collected and Gallons Blended or Dyed Fuel Used 6 Gallons Delivered Via Rail, Pipeline or Vessel to Licensed Suppliers, Tax Not Collected 6D Gallons Sold to Licensed Distributors, Tax Not Collected (Gasoline Only) 6X Gallons Disbursed on Exchange 7 Gallons Exported to State of (Must be filed in duplicate) 7A Special Fuel Gallons Sold to Unlicensed Exporters for Export to State of (Dest. State Tax Collected) (Must be filed in duplicate) 5 7B Special Fuel Gallons Sold to Licensed Exporters for Export to State of (Must be filed in duplicate) 8 Gallons of Undyed Special Fuel, Gasoline and Kerosene sold to the U.S. Government Tax Exempt 8K Kerosene Sales (SF-900 information only) 10 Gallons Sold of Tax Exempt Dyed Fuel 10A Gallons Delivered to Marina Fuel Dealers 10B Gallons Delivered to Aviation Fuel Dealers Transporter Information (3) (1) Name (2) FEIN (4) Point of (5) (6) Sold To Sales / Delivery Information Mode Origin Dest. Term. (State) (State) Code (7) FEIN (8) Date Sent (9) Document Number (10) Net Gallons (11) Gross Gallons (12) Billed Gallons Total American LegalNet, Inc. www.FormsWorkflow.com Instructions for Completing Schedule of Disbursements Schedules 5 - 10 Before you begin: These schedules provide detail in support of the amount(s) shown as disbursements on the Consolidated Special Fuel Monthly Tax Return, Form SF-900, and Consolidated Gasoline Monthly Tax Return, Form MF-360. Enter your identifying information as it is reflected on your Indiana Fuel Tax License. Be certain to check the appropriate schedule type that you are completing, as well as the product type, and complete a separate schedule for each fuel product type. Disbursements should be reported on only one schedule. Sales of dyed product for export will be reported as an export, not a sale of dyed product. Schedule Type: Indicate the appropriate schedule type you are completing: 5 Gallons Delivered, Tax Collected and Gallons Blended or Dyed Fuel Used 6 Gallons Delivered Via Rail, Pipeline, or Vessel To Licensed Suppliers, Tax Not Collected 6D Gallons Sold to Licensed Distributor, Tax Not Collected (Gasoline Only) 6X Gallons Disbursed on Exchange Through Exchange Agreements 7 Gallons Exported to State of ___________________ (Must be filed in duplicate) 7A Special Fuel Gallons Sold to Unlicensed Exporters for Export to State of ________________________ (Must be filed in duplicate) 7B Special Fuel Gallons Sold to Licensed Exporters for Export to State of _________________________ (Must be filed in duplicate) 8 Gallons of Undyed Special Fuel, Gasoline & Kerosene Sold to the U.S. Government - Tax Exempt 8K Kerosene Sales (SF-900 Information Only) 10 Gallons Sold of Tax Exempt Dyed Fuel 10A Gallons Delivered to Marina Fuel Dealers 10B Gallons Delivered to Aviation Fuel Dealers Column Instructions: Columns 1 and 2: Enter the name and Federal Identification Number (FEIN) of the company that transports the fuel. This may or may not be your company. Column 3: Enter the mode of transport. One of the following codes should be used for each entry. J R B BA = = = = Truck Rail Barge Book Adjustment PL = Pipeline S = Ship (Great Lakes or Ocean Vessel) ST = Stock Transfer Column 4: Enter the point of origin and destination state. Column 5: Enter the terminal code number assigned by the Internal Revenue Service (IRS). Columns 6-9: Enter the purchaser's name and Federal Identification Number (FEIN), the date sent, and document number. Invoice numbers cannot be used in lieu of bill of lading or manifest numbers. Column 10: Enter the net gallons. Column 11: Enter the gross gallons. Column 12: Enter the billed (invoiced) gallons. These should equal either net or gross gallons. American LegalNet, Inc. www.FormsWorkflow.com