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Form 720: Collection Information Statement

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Collection Information Statement
Part I
IRS No.Environmental Taxes (attach Form 6627)TaxIRS No.
1818
2121
9898
1919
IRS No.Communications and Air Transportation Taxes (see instructions)TaxIRS No.
2222
2626
2828
2727
60Fuel TaxesNumber of gallonsRateTax
60
104104
105105
107107
119119
35
35
6969
7777
111111
7979
62
62
1313
1414
112112
118118
120120
121121
122122
123123
124124
IRS No.RateTaxIRS No.
3333
29Ship Passenger TaxNumber of personsRateTax
29
31Other Excise TaxNumber of personsRateTax
31
30Foreign Insurance Taxes—Policies issued by foreign insurersPremiums paidRateTaxIRS No.
30
Manufacturers TaxesNumber of tonsSales price
3636
3737
3838
3939
Number of tiresTaxIRS No.
108108
109109
113113
40 40
9797
136ReservedSales price2.3% of sales price136
1$
Part II
IRS No.Patient Centered Outcomes Research Fee (see instructions)(a) Avg. number of lives covered (see inst.)(b) Rate for avg. covered life(c) Fee (see instructions)TaxIRS No.
133Specified health insurance policies133
$
$
$
$
41Rate
41
110110
4242
114114
4444
106106
140140
64Number of gallonsRateTax64
125125
5151
117117
2020
2$
Part III
33
44
55
66
77
88
99
1010
11 11
Schedule A Excise Tax Liability (see instructions)
Note: You must complete Schedule A if you have a liability for any tax in Part I of Form 720. Do not complete Schedule A for Part II taxes or for a one-time filing of the gas guzzler tax.
1Regular method taxes
(a) Record of Net Tax LiabilityPeriod
1st–15th day16th–last day
AB
CD
EF
Special rule for September ▸G
2Alternative method taxes (IRS Nos. 22, 26, 28, and 27)
(a) Record of Taxes Considered as CollectedPeriod
1st–15th day16th–last day
MN
OP
QR
Special rule for September ▸S
*Complete only as instructed (see instructions).
Schedule T Two-Party Exchange Information Reporting (see instructions)
FuelNumber of gallons
Schedule C Claims  
• Complete Schedule C for claims only if you are reporting liability in Part I or II of Form 720.
• Attach a statement explaining each claim as required. Include your name and EIN on the statement (see instructions). Caution: Claimant has the name and address of the person(s) who sold the fuel to the claimant, the dates of purchase, and if exported, the required proof of export. For claims on lines 1a and 2b (type of use 13 and 14), 3c, 4b, and 5, claimant has not waived the right to make the claim.
1Nontaxable Use of Gasoline   Note: CRN is credit reference number.  
aType of useRateGallonsAmount of claimCRN
362
b411
2Nontaxable Use of Aviation Gasoline  
aType of useRateGallonsAmount of claimCRN
354
b324
c412
d433
3Nontaxable Use of Undyed Diesel Fuel  
Claimant certifies that the diesel fuel did not contain visible evidence of dye.
Exception. If any of the diesel fuel included in this claim did contain visible evidence of dye, attach a detailed explanation and
aType of useRateGallonsAmount of claimCRN
360
b353
c350
d360
e413
4Nontaxable Use of Undyed Kerosene (Other Than Kerosene Used in Aviation)  
Claimant certifies that the kerosene did not contain visible evidence of dye.
Exception. If any of the kerosene included in this claim did contain visible evidence of dye, attach a detailed explanation and check here ▸
aType of useRateGallonsAmount of claimCRN
362
b347
c346
d414
e377
f369
5Kerosene Used in Aviation (see Caution above line 1)  
aType of useRateGallonsAmount of claimCRN
417
b355
c346
d369
e433
6Nontaxable Use of Alternative Fuel
Caution: There is a reduced credit rate for use in certain intercity and local buses (type of use 5) (see instructions).
aType of useRateGallons, or gasoline or diesel gallon equivalentsAmount of claimCRN
$419
b420
c421
d422
e423
f424
g425
h435
7Sales by Registered Ultimate Vendors of Undyed Diesel Fuel
Claimant certifies that it sold the diesel fuel at a tax-excluded price, repaid the amount of tax to the buyer, or has obtained written consent of the buyer to make the claim. Claimant certifies that the diesel fuel did not contain visible evidence of dye.
aRateGallonsAmount of claimCRN
$360
b350
8Sales by Registered Ultimate Vendors of Undyed Kerosene (Other Than Kerosene For Use in Aviation)
Claimant certifies that it sold the kerosene at a tax-excluded price, repaid the amount of tax to the buyer, or has obtained the written consent of the buyer to make the claim. Claimant certifies that the kerosene did not contain visible evidence of dye.
aRateGallonsAmount of claimCRN
$346
b
c347
9Sales by Registered Ultimate Vendors of Kerosene For Use in Aviation
Claimant sold the kerosene for use in aviation at a tax-excluded price and has not collected the amount of tax from the buyer, repaid the amount of tax to the buyer, or has obtained written consent of the buyer to make the claim. See the instructions for additional information to be submitted.
aType of useRateGallons, or gasoline or diesel gallon equivalentsAmount of claimCRN
$355
b$417
c$418
d$346
e$369
f$433
10Sales by Registered Ultimate Vendors of Gasolin
Claimant sold the gasoline at a tax-excluded price and has not collected the amount of tax from the buyer, repaid the amount of tax to the buyer, or has obtained written consent of the buyer to take the claim; and obtained an unexpired certificate from the buyer and has no reason to believe any information in the certificate is false. See the instructions for additional information to be submitted.
aRateGallonsAmount of claimCRN
$362
b
11Sales by Registered Ultimate Vendors of Aviation Gasoline
Claimant sold the aviation gasoline at a tax-excluded price and has not collected the amount of tax from the buyer, repaid the amount of tax to the buyer, or has obtained written consent of the buyer to take the claim; and obtained an unexpired certificate from the buyer and has no reason to believe any information in the certificate is false. See the instructions for additional information to be submitted.
aRateGallonsAmount of claimCRN
$324
b
12Biodiesel or Renewable Diesel Mixture Credit  
Biodiesel mixtures. Claimant produced a mixture by mixing biodiesel with diesel fuel. The biodiesel used to produce the mixture met ASTM D6751 and met EPA's registration requirements for fuels and fuel additives. The mixture was sold by the claimant to any person for use as a fuel or was used as a fuel by the claimant. Claimant has attached the Certificate for Biodiesel and, if applicable, the Statement of Biodiesel Reseller. Renewable diesel mixtures. Claimant produced a mixture by mixing renewable diesel with liquid fuel (other than renewable diesel). The renewable diesel used to produce the renewable diesel mixture was derived from biomass, met EPA's registration requirements for fuels and fuel additives, and met ASTM D975, D396, or other equivalent standard approved by the IRS. The mixture was sold by the claimant to any person for use as a fuel or was used as a fuel by the claimant. Claimant has attached the Certificate for Biodiesel and, if applicable, Statement of Biodiesel Reseller, both of which have been edited as discussed in the instructions for line 13. See the instructions for line 13 for information about renewable diesel used in aviation.
RateGallonsAmount of claimCRN
a388
b390
c307
13Alternative Fuel Credit and Alternative Fuel Mixture Credit
For the alternative fuel mixture credit, claimant produced a mixture by mixing taxable fuel with alternative fuel. Claimant certifies that it (a) produced the alternative fuel, or (b) has in its possession the name, address, and EIN of the person(s) that sold the alternative fuel to the claimant; the date of purchase; and an invoice or other documentation identifying the amount of the alternative fuel. The claimant also certifies that it made no other claim for the amount of the alternative fuel, or has repaid the amount to the government. The alternative fuel mixture was sold by the claimant to any person for use as a fuel or was used as a fuel by the claimant.
RateGallonsAmount of claimCRN
a426
b427
c428
d429
e430
f431
g432
h436
i437
14Other claims. See the instructions. For lines 14b and 14c, see the Caution above line 1 on page 5.Amount of claimCRN
a$366
b415
c416
d
e
fNumber of tiresAmount of claimCRN
396
g304
h305
i
j
k
1515

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