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 YEAR IFTA DECALS WITH THIS RETURN) NAME AND/OR ADDRESS CHANGE ENCLOSED SECTION 7. MILES PER GALLON CALCULATION 7A FUEL 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 DUE TOTAL DUE/ REFUND (8I PLUS 8J) ROUND TO THE NEAREST WHOLE GALLON AND MILE VA 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 - LP Ethanol - ET Methanol - MT Compressed Natural Gas - CNG-CN Diesel/Methanol - M-85-M8 Liquid Natural Gas - LNG-LN Diesel/Ethanol - E-85-E8 Water/Naptha - A55-A5 Surtax - ST