RDT 121 (07/05/2017)

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) mcsonline@dmv.virginia.gov (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-CNMethanol/Gasoline - M-85-M8 Liquid Natural Gas - LNG-LNEthanol/Gasoline - E-85-E8 Water/Naphtha - A55-A5 Surtax - ST

RDT 121 (07/05/2017) -- Page 2

4. IFTA LICENSE NUMBER (FEIN OR SSN)2. QUARTERLY REPORTING PERIOD

QUARTERLY TAX RETURN

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 $ $ $

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

$

$

1. CARRIER NAME

CERTIFICATION

PRINT NAME PRINT TITLE

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 ( )

TELEPHONE NUMBER DATE (mm/dd/yyyy)SIGNATURE

PAYMENT METHODS

ACH Debit authorized per signature below:

(check one)CREDIT CARD / E-CHECK -- Provide contact name and number belowACH DEBIT -- Authorize by signing belowCHECK / MONEY ORDER -- Made payable to DMV

NOTE: In our continuing effort to safeguard customer information, DMV does not accept credit card payments by mail or email. You may pay with a credit card by having a Motor Carrier Services Representative contact you. We accept checks and money orders via mail.

TELEPHONE NUMBER DATE (mm/dd/yyyy)SIGNATURECONTACT NAME (print)