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Motor Fuel Tax - Diesel

For filing month and year of

Business Name

Business Address

Mailing Address

Municipal Motor Fuel Tax - Diesel, Under Article 24A Of The Revised Code Of Ordinances

Gallon measurement is necessary to complete this return. Please convert liter measurements into U.S. gallons (# of liters x .2641721).

Section A: Retail Diesel Motor Fuel Sales

Pump Number

Type

Diesel

Bio-Diesel

Beginning Pump Reading

Ending Pump Reading

Add Remove

Total number of gallons for the month, (ending reading minus beginning reading)

Section B: Bulk User Diesel Fuel Purchases

Total number of gallons of Diesel/Bio-Diesel fuel purchased during the filing month.

Section C: Total Diesel Fuel Gallons

Total number of Diesel fuel gallons subject to tax. (Add section A and Section B totals)

Section D: Calculation of Tax and Penalty

Total number of Diesel fuel gallons subject to tax (From Section C)

Amount of tax (multiply total number of gallons by .02)

Penalty of 2% per month, if filed late or past due

Total Tax and Penalty to be remitted

If this is a Final return, or there has been a change in ownership, please complete the following:

Date Business Sold

Date Business Discontinued

Former Owners Contact Address

New Owner's Name

New Owner's Contact Address

Name of person preparing this return.

Name of Firm or Employer

Phone Number

I certify that the information provided is true, accurate, and complete and that the information is taken from the books and records of the business for which this return is filed.

Yes