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RDT 121 (01/03/2014)1. CARRIER NAME AND MAILING ADDRESS
3. DUE DATE
4. IFTA LICENSE NUMBER (FEIN OR SSN)
IMPORTANT NOTE: Refer to instructions (form RDT 121 I) before completing this return. Failure to correctly complete this return may subject the carrier to penalty and interest. For assistance please contact DMV Motor Carrier Services at: (804) 249-5130 (Voice) (800) 272-9268 (deaf or hearing impaired) (804) 367-1073 (Fax) [email protected] (email)6. NOTICE OF CHANGE (CHECK THE FOLLOWING BOXES IF ANY APPLY TO THIS RETURN)
AMENDED RETURN (REFILE ALL INFORMATION, NOT JUST ADDITIONS)CLOSE IFTA ACCOUNT/CANCEL LICENSE (ATTACH ALL CURRENT YEARIFTA DECALS WITH THIS RETURN)NAME AND/OR ADDRESS CHANGE ENCLOSED
SECTION 7. MILES PER GALLON CALCULATION7AFUEL TYPE CODE 7B ALL MILES TRAVELED (IFTA + NON-IFTA)
(ROUNDED) 7C TOTAL GALLONS PLACED IN ALL QUALIFIED VEHICLES 7D AVERAGE MILES PER GALLON (MPG)
DI
GA
TOTALS
SECTION 8. FUEL TAX CALCULATION
8A 8B 8C 8D 8E 8F 8G 8H 8I 8J 8K
JURIS ABBR.
FUEL TYPE CODE TOTAL MILES TAXABLE MILES
TAXABLE GALLONS (8D DIVIDED BY
7D)
GALLONS PURCHASED AND PLACED IN VEHICLES
NET TAXABLE GALLONS
(8E MINUS 8F)
TAX RATE
TAX DUE/REFUND (8G
TIMES 8H)INTEREST
DUETOTAL DUE/
REFUND (8I PLUS 8J)
ROUND TO THE NEAREST WHOLE GALLON AND MILEVA DI $ $ $
VA ST-DI 0 $ $ $
VA GA $ $ $
VA ST-GA 0 $ $ $
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $(8M) SUBTOTALS THIS PAGE
$ $ $
CHECK ONE (if applicable)
INTERNATIONAL FUEL TAX AGREEMENT (IFTA) QUARTERLY TAX RETURN
2. QUARTERLY REPORTING PERIOD
5A CHECK IF YOU DID NOT OPERATE TAX-QUALIFIED MOTOR VEHICLES THIS QUARTER IN ANY IFTA JURISDICTION.
5B CHECK IF YOU OPERATED IN A JURISDICTION WHERE A TAXABLE MILEAGE EXEMPTION APPLIES. (ENTER JURISDICTION & EXEMPTION)
JURISDICTION EXEMPTION
JURISDICTION EXEMPTION
FUEL TYPE CODES:Gasoline - GA Gasohol - GH Special Diesel - DI Biodiesel - BD Propane - LPEthanol - ET Methanol - MT Compressed Natural Gas - CNG-CNDiesel/Methanol - M-85-M8 Liquid Natural Gas - LNG-LNDiesel/Ethanol - E-85-E8 Water/Naptha - A55-A5 Surtax - ST
RDT 121 (01/03/2014)
4. IFTA LICENSE NUMBER (FEIN OR SSN)2. QUARTERLY REPORTING PERIOD
QUARTERLY TAX RETURN, page 2
8. FUEL TAX CALCULATION - CHART B (MAKE ADDITIONAL COPIES OF THIS PAGE IF NEEDED)
8A 8B 8C 8D 8E 8F 8G 8H 8I 8J 8K
JURIS ABBR.
FUEL TYPE CODE TOTAL MILES TAXABLE MILES
TAXABLE GALLONS (8D DIVIDED BY
7D)
GALLONS PURCHASED AND PLACED IN VEHICLES
NET TAXABLE GALLONS
(8E MINUS 8F)
TAX RATE
TAX DUE/REFUND (8G
TIMES 8H)INTEREST
DUETOTAL DUE/
REFUND (8I PLUS 8J)
ROUND TO THE NEAREST WHOLE GALLON AND MILE$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
(8L)NON-IFTA DI NON-IFTA MILES GA GALLONS
(8M) SUBTOTALS THIS PAGE
$ $ $
(8N) SUBTOTALS ALL ADDITIONAL PAGES $ $ $
(8O) SUBTOTALS FROM FRONT PAGE $ $ $
MUST EQUAL 7B SHOULD EQUAL 7C(8P) TOTALS $ $ $
YOU MAY PAY BY CHECK OR MONEY ORDER MADE PAYABLE TO DMV OR COMPLETE CHARGE CARD INFORMATION ABOVE TO PAY BY CREDIT CARD.
MAIL RETURN WITH PAYMENT TO:
DEPARTMENT OF MOTOR VEHICLES MOTOR CARRIER SERVICES POST OFFICE BOX 27412 RICHMOND, VA 23269-0001
(8R) LATE FEE -- SEE INSTRUCTIONS(8S) GRAND TOTAL DUE/REFUND
$
$
CERTIFICATION
SIGNATURE DATE (mm/dd/yyyy) TELEPHONE NUMBER ( )
PRINT NAME PRINT TITLE
CHARGE CARD INFORMATIONNAME APPEARING ON CREDIT CARD DAYTIME TELEPHONE NUMBER
( )CREDIT CARD NUMBER
DATE CARD EXPIRES (MM/YY)
AMOUNT TO BE CHARGED $
I hereby authorize DMV to charge the credit card account listed.
CARD HOLDER SIGNATURE DATE (mm/dd/yyyy)
I certify and affirm that all information presented in this return is true, correct and complete and that any documents I have presented to DMV are genuine, and that the information included in all supporting documentation is true and accurate. I make this certification and affirmation under penalty of perjury and I understand that knowingly making a false statement or representation on this return is a criminal violation.
EMAIL ADDRESS FAX NUMBER ( )
1. CARRIER NAME
