Free DR-309637 - Florida

Petroleum Carrier Information Return

DR-309637 R. 01/09 Page 1
Rule 12B-5.150 Florida Administrative Code Effective 06/09

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Handwritten Example

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Typed Example

Use black ink.

Complete and return coupon to the Department of Revenue.

IMPORTANT

COMPLETE FORM DR-309637 BEFORE ENTERING INFORMATION ON THE ATTACHED COUPON.
Mail the original of this form along with coupon to the: Florida Department of Revenue 5050 W Tennessee St Tallahassee Fl 32399-0165

Detach here
Mail To: Florida Department of Revenue 5050 W Tennessee St Tallahassee FL 32399-0165

Detach here

Petroleum Carrier Information Return Coupon
COMPLETE and MAIL with your RETURN DoR USE oNly
PoSTMARk oR hAND DElIvERy DATE

DR-309637 R. 01/09

FEIN ENTER BUSINESS NAME:

Do Not Write in the Space Below

DR-309637

FoR PERIoD ENDINg

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DR-309637 R. 01/09 Page 2

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Mail To: Florida Department of Revenue 5050 W Tennessee St Tallahassee FL 32399-0165

Petroleum Carrier Information Return

DR-309637 R. 01/09 Page 3

Check here if amending return
FEIN: License Number: Collection Period Ending:

Return Due By

Late After

Complete Reverse Side of Return First

Under penalties of perjury, I swear or affirm that this return, including any accompanying schedules and statements, has been examined by me and it is true, correct and complete for the collection period stated.

_______________________________________________________________________________________________________________________
Signature of Carrier Title Date

_______________________________________________________________________________________________________________________
Name of Preparer (Print) Signature of Preparer Telephone Number FEIN Date

DR-309637 R. 01/09 Page 4
Company Name FEIN Collection Period Ending (mm/dd/yy)

gAlloNS
DIESEL

A. Gasoline
1. Total gallons of petroleum product loaded at a Florida terminal or bulk plant and delivered to another state (Attach Schedule 14A): ........................................................... 2. Total gallons of petroleum product loaded at an out-of-state terminal or bulk plant facility and delivered in Florida (Attach Schedule 14B): ............................................ 3. Total gallons of petroleum product loaded at a Florida terminal or bulk plant and delivered in Florida (Attach Schedule 14C): ...........................................

B. Undyed

C. Dyed

D. Aviation

4. Total gallons of petroleum product transported (Total of Lines 1 through 3): .....

Petroleum Carrier Information Return Schedule 14 - Schedule of deliveries

Check here if amending schedule
FEIN Terminal Code/Origin Collection Period Ending (mm/ dd/yy)

Schedule/Product Type

Company Name

DR-309637 R. 01/09 Page 5

Schedule Type - only one product type per schedule type: Product Type:
065 072 124 125 130 142 Gasoline Dyed Kerosene Gasohol Aviation Gasoline jet Fuel Undyed Kerosene 167 Low Sulphur Diesel #2/ Undyed/Blended Biodiesel (B20, B10, B5, B2) 224 Compressed Natural Gas/ Propane 226 High Sulphur Diesel Fuel Dyed 227 Low Sulphur Diesel Fuel - Dyed B00 Undyed/Unblended Biodiesel (B100) D00 Dyed Biodiesel (B100) E00 Ethanol (percent of ethanol equals 99.1% or more)

14A. Gallons Loaded at a Florida Terminal or Bulk Plant and Delivered to Another State 14B. Gallons Loaded at an Out-of-State Terminal or Bulk Plant and Delivered in Florida 14C. Gallons Loaded at a Florida Terminal or Bulk Plant and Delivered in Florida.

Person hiring the carrier:
(4) FEIN (6) (5) OriMode gin (7) Name (8) Address (9) FEIN

Seller

Delivered to:
(10) Date Delivered (12) (11) Gross Document GalNumber lons (13) Net Gallons

(1) Company Name

(2) FEIN

(3) Company Name

Subtotal

Petroleum Carrier Information Return (continued) Schedule 14 - Schedule of deliveries

Check here if amending schedule
FEIN Terminal Code/Origin Collection Period Ending (mm/ dd/yy)

Schedule/Product Type

Company Name

DR-309637 R. 01/09 Page 6

Person hiring the carrier:
(4) FEIN (6) (5) OriMode gin (7) Name (8) Address (9) FEIN (10) Date Delivered (12) (11) Gross Document GalNumber lons

Seller

Delivered to:
(13) Net Gallons

(1) Company Name

(2) FEIN

(3) Company Name

Total