KANSAS DEPARTMENT OF REVENUE CUSTOMER RELATIONS 915 SW HARRISON ST. TOPEKA, KANSAS 66612-1588 www.ksrevenue.org
Phone Number: (785) 368-8222 FAX (785) 296-4993 PETROLEUM PRODUCTS INSPECTION REPORT For month of
NOTE: This report must be prepared for each
calendar month, and filed not later than the 25th
of the following month.
PETROLEUM PRODUCTS INSPECTION FEE
1. Gasoline and Diesel Instate (from schedule on reverse side) ........................................................................................... 2. Gasoline and Diesel Imported (from schedule on reverse side) ....................................................................................... 3. Total gallons of liquid fuels subject to inspection fee (Add lines 1 and 2) ...................................................................... 4. Total barrels subject to inspection fee (total gallons line 3 divided by 50)...................................................................... 5. Petroleum Products Inspection fee at $.015 per barrel (line 4 times .015) ...................................................................... $
6. Penalty at 5% plus appropriate % of interest per month as found on our web site, for delinquent filing ........................ $
7. Total Petroleum Products Inspection fee, penalty and interest (line 5 plus line 6) .......................................................... $
8. Approved Petroleum Products Inspection fee Credit Memo applied ............................................................................... $
9. Total Petroleum Products Inspection fee remittance (line 7 minus line 8)....................................................................... $
ENVIRONMENTAL ASSURANCE FEE
10. Total gallons of petroleum products manufactured or imported...................................................................................... 11. Exports shipped directly.................................................................................................................................................. 12. Total gallons of petroleum products subject to assurance fee (line 10 minus line 11)..................................................... 13. Assurance fee at $.01 per gallon (line 12 times $.01)......................................................................................................
When line 13 is marked out (XXXXXXXXXX) do not remit the environmental assurance fee.
$XXXXXXXXXXXXXXXXX
14. Penalty at 5% plus appropriate % of interest per month as found on our web site, for delinquent filing ........................ $
15. Total Assurance Fee, penalty and interest (line 13 plus line 14) ..................................................................................... $
16. A
pproved Environmental Assurance fee Credit Memo applied....................................................................................... $
17. Total Environmental Assurance fee remittance (line 15 minus line 16)........................................................................... $
18. TOTAL AMOUNT REMITTED (line 9 plus line 17) .....................................................................................................
$
INSTRUCTIONS
Petroleum Products Inspection Fee
Line 1: All gasoline and diesel gallons first sold, offered for sale, used or delivered in the state of Kansas, including fuel that has been exported, sales of
aviation/jet fuel and sales to the U.S. government.
Line 2: All gasoline and diesel gallons imported into the state of Kansas.
Environmental Assurance Fee
"Petroleum" means petroleum, including crude oil or any fraction thereof, which is liquid at standard conditions of temperature and pressure (60 degrees
Fahrenheit and 14.7 pound per square inch absolute) including, but not limited to, gasoline, gasohol, diesel fuel, fuel oils, kerosene and biofuels.
"Petroleum Product" means petroleum other than crude oil.
Signature
MF-7a
(Rev. 6/13)
Telephone No.
LIST LIQUID FUELS AND PETROLEUM PRODUCTS SOLD, DELIVERED OR USED
Date
Loaded
Manifest
(Bill of Lading)
Number
CONSIGNEE
DESTINATION
INVOICED GALLONS
Product
Code
Gallons