Schedules 5 through 10 SF# 49082 (R3 \ 12-08) Schedule of Disbursements License Number Company Name □ 7A Schedule Type (Check One) □ 5 □ 6 Gallons Delivered Via Rail, Pipeline or Vessel to Licensed Suppliers, Tax Not Collected (Special Fuel) Special Fuel Gallons Sold to Unlicensed Exporters for Export to State of (Dest. State Tax Collected) (Must be filed in duplicate) Gallons Delivered, Tax Collected and Gallons Blended or Dyed Fuel Used Gallons Sold to Licensed Distributors, Tax Not Collected (Gasoline Only) □ 6D □ 6X □ 7 Gallons Disbursed on Exchange Gallons Exported to State of (Must be filed in duplicate) Transporter Information (1) Name (2) FEIN (3) (4) Point of Month / Year Fein □ 7B □ 8 Special Fuel Gallons Sold to Licensed Exporters for Export t State of (Must be filed in duplicate) You may photocopy this blank schedule for future filings. Attach additional sheets if necessary. Gallons of Undyed Special Fuel, Gasoline and Kerosene sold to the U.S. Government Tax Exempt Please see the product code matrix on the Web site at www.in.gov/dor/reference/files/code-matrix.pdf □ 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 (5) Mode Origin Dest. Term. (State) (State) Code Sales / Delivery Information (6) Sold To (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 (Special Fuel) 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 ___________________ 7A Special Fuel Gallons Sold to Unlicensed Exporters for Export to State of ________________________ 7B Special Fuel Gallons Sold to Licensed Exporters for Export to State of _________________________ 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). If the fuel is biodiesel you may use BIO, if it comes from bulk storage, use BULK. 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