Form R-5375 Interstate Motor Fuels User Quarterly Tax Return - Louisiana

Form R-5375 is a Louisiana Department of Revenue form also known as the "Interstate Motor Fuels User Quarterly Tax Return". The latest edition of the form was released in July 1, 2006 and is available for digital filing.

Download a PDF version of the Form R-5375 down below or find it on Louisiana Department of Revenue Forms website.

Step-by-step Form 5375 instructions can be downloaded by clicking this link.

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R-5375 (7/06)
If your name has
If your address has
If amended return,
If final return,
O
O
O
O
changed, mark circle.
changed, mark circle.
mark circle.
mark circle.
INTERSTATE MOTOR FUELS USER
Account Number
QUARTERLY TAX RETURN
Name(1)
Mail to:
Louisiana Department of Revenue
Address(1)
P. O. Box 201
Baton Rouge, LA 70821-0201
Address(2)
(225) 219-7656 (225) 219-2114 (TDD)
City
State
ZIP
FOR OFFICE USE ONLY.
F i e l d f l a g
IMU
Filing
Period_____________________
MM/YY
Round to nearest
Type of fuel used:
Diesel
LPG
Other
Gallon/Dollar
1 Total miles traveled in all states (Schedule A, Total from Column 2)
2 Total gallons of fuel consumed in all states (Schedule A, Total from Column 3)
3 Average miles per gallon (Divide Line 1 by Line 2 and round to 2 decimal places.)
4 Miles traveled in Louisiana (Schedule A, Column 2, “Louisiana” line)
5 Fuel used in Louisiana (Divide Line 4 by Line 3.)
6 Fuel placed in vehicles in Louisiana (Schedule B, Section 4)
7 Taxable gallons (If Line 5 is greater than Line 6, enter the difference)
8 Credit gallons *(If Line 6 is greater than Line 5, enter the difference)
9 Tax due *(Multiply Line 7 by $.20.)
9
$
00
10 Penalty (See instructions.)
10
$
00
11 Interest (See instructions.)
11
$
00
Total amount due (Add Lines 9, 10, and 11.)
12
12
Pay this amount.
Make payment to: Louisiana Department of Revenue
Do not send cash.
$
00
*No refund will be made for less than $3.00.
This return is due on or before the 25th day of the month following the period covered and becomes delinquent the first day thereafter. If the due date falls
on a legal holiday or weekend, the return is due the next business day after the due date.
Under the penalties of perjury, I declare that I have examined this return, including all accompanying documents, and to the best of my knowledge and
belief, it is true, correct, and complete. If a person other than the taxpayer prepares the return, this declaration is based on all the information relating to
the matters required to be reported of which the preparer has knowledge.
Date
Signature
Title
Telephone number
Complete only if change in business status has occurred. Please print or type.
Date business discontinued
Date business sold
Name of purchaser
7673
R-5375 (7/06)
If your name has
If your address has
If amended return,
If final return,
O
O
O
O
changed, mark circle.
changed, mark circle.
mark circle.
mark circle.
INTERSTATE MOTOR FUELS USER
Account Number
QUARTERLY TAX RETURN
Name(1)
Mail to:
Louisiana Department of Revenue
Address(1)
P. O. Box 201
Baton Rouge, LA 70821-0201
Address(2)
(225) 219-7656 (225) 219-2114 (TDD)
City
State
ZIP
FOR OFFICE USE ONLY.
F i e l d f l a g
IMU
Filing
Period_____________________
MM/YY
Round to nearest
Type of fuel used:
Diesel
LPG
Other
Gallon/Dollar
1 Total miles traveled in all states (Schedule A, Total from Column 2)
2 Total gallons of fuel consumed in all states (Schedule A, Total from Column 3)
3 Average miles per gallon (Divide Line 1 by Line 2 and round to 2 decimal places.)
4 Miles traveled in Louisiana (Schedule A, Column 2, “Louisiana” line)
5 Fuel used in Louisiana (Divide Line 4 by Line 3.)
6 Fuel placed in vehicles in Louisiana (Schedule B, Section 4)
7 Taxable gallons (If Line 5 is greater than Line 6, enter the difference)
8 Credit gallons *(If Line 6 is greater than Line 5, enter the difference)
9 Tax due *(Multiply Line 7 by $.20.)
9
$
00
10 Penalty (See instructions.)
10
$
00
11 Interest (See instructions.)
11
$
00
Total amount due (Add Lines 9, 10, and 11.)
12
12
Pay this amount.
Make payment to: Louisiana Department of Revenue
Do not send cash.
$
00
*No refund will be made for less than $3.00.
This return is due on or before the 25th day of the month following the period covered and becomes delinquent the first day thereafter. If the due date falls
on a legal holiday or weekend, the return is due the next business day after the due date.
Under the penalties of perjury, I declare that I have examined this return, including all accompanying documents, and to the best of my knowledge and
belief, it is true, correct, and complete. If a person other than the taxpayer prepares the return, this declaration is based on all the information relating to
the matters required to be reported of which the preparer has knowledge.
Date
Signature
Title
Telephone number
Complete only if change in business status has occurred. Please print or type.
Date business discontinued
Date business sold
Name of purchaser
7673

Download Form R-5375 Interstate Motor Fuels User Quarterly Tax Return - Louisiana

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