Heavy Highway Vehicle Use Tax Return Form 2290

(Rev. July 2003) For the period July 1, 2003, through June 30, 2004

Department of the Treasury

Internal Revenue Service

 Attach both copies of Schedule 1 to this return.

Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and, to the best of my

knowledge and belief, they are true, correct, and complete.

Signature

Type or print name below signature.

For Privacy Act and Paperwork Reduction Act Notice, see page 7 of the instructions. Cat. No. 11250O Form 2290 (Rev. 7-2003)

OMB No. 1545-0143

FOR IRS

USE ONLY

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FF

FP

I

Name

Check here if:

City, state, and ZIP code (For Canadian or Mexican address, see page 3 of the instructions.)

Address (number, street, and room or suite no.)

Employer identification number

Detach here

OMB No. 1545-0143

Form 2290-V

Department of the Treasury

Internal Revenue Service

Payment Voucher

1

4 Name

 Do not staple or attach this voucher or your payment to your return.

Address

(99)

See How to Make Your Payment on page 5.

Employer identification number 2

Send Form 2290, this voucher, and payment to:

Internal Revenue Service

P.O. Box 105421

Atlanta, GA 30348-5421

Telephone number ( )

3 Enter date as shown on line 1 of Form 2290.

(Rev. July 2003)

Type

or Print

Address

change

Final return

YYYM

For the period July 1, 2003, through June 30, 2004

Keep a copy of this

return for your records.

T

Was the vehicle(s) reported on this return used on public highways during July 2003?

If YES, enter 200307 in the boxes to the right. If NO, see page 3 of the instructions 

Total tax. Enter the Totals from Form 2290, page 2, column (4)

1

Additional tax from increase in taxable gross weight. See page 3 of the instructions 

2

Credits. See page 3 of the instructions 

3

Tax as adjusted. Add lines 2 and 3, then subtract line 4 from the total. This is the amount you

owe. If paying in installments, go to line 6. If payment through EFTPS, check here. 

4

Installment payment. See page 5 of the instructions

5

I declare that the vehicles listed in Part II of Schedule 1 are expected to be used on public highways (check the boxes that

apply):

6

8a I declare that the vehicles listed as suspended on the Form 2290 filed for the period July 1, 2002, through June 30, 2003, were not

subject to the tax for that period except for any vehicles listed on line 8b. Check this box if applicable. 

9 I declare that vehicle identification numbers

were listed as suspended on the Form 2290 filed for the period July 1, 2002, through June 30, 2003. These vehicles were

sold or transferred to on , .

At the time of the transfer, the vehicles were still eligible for the suspension of the tax. Attach a separate list if needed.

5,000 miles or less 7,500 miles or less for agricultural vehicles

during the period July 1, 2003, through June 30, 2004, and are suspended from the tax. Complete and attach Schedule 1.

Part I

Part II

Figuring the Tax

Y YMM

Statement in Support of Suspension (Complete the statements that apply. Attach additional sheets if needed.)

7

1

2

3

4

5

6

Y Y

 See the separate instructions.

City, state, and ZIP code (For Canadian or Mexican address, see instructions.)

Y M

b Vehicle identification numbers

Sign

Here   Date

Enter the amount of your payment.

Dollars Cents

Third

Party

Designee Designee’s

name 

Do you want to allow another person to discuss this return with the IRS (see instructions)?

Phone

no.  ( )

Yes. Complete the following. No

Personal identification

number (PIN) 
Tax Computation

(2)

Partial-period tax

(vehicles first used after July)

(See the tables on page 8 of

the instructions.)

(4)

Amount of tax

(col. (1) or (2)

times col. (3))

(1)

Annual tax

(vehicles used

during July)

(3)

Number of

vehicles

Category

(b)

Logging or

Canadian/

Mexican*

Vehicles

(a)

Vehicles Except

Logging or

Canadian/

Mexican*

(b)

Logging or

Canadian/

Mexican*

Vehicles

(a)

Vehicles Except

Logging or

Canadian/

Mexican*

(b)

Logging or

Canadian/

Mexican*

Vehicles

(a)

Vehicles Except

Logging or

Canadian/

Mexican*

Taxable Gross Weight

(in pounds)

55,000 $100.00 $75.00 A

55,001 – 56,000 122.00 91.50 B

56,001 – 57,000 144.00 108.00 C

57,001 – 58,000 166.00 124.50 D

58,001 – 59,000 188.00 141.00 E

59,001 – 60,000 210.00 157.50 F

60,001 – 61,000 232.00 174.00 G

61,001 – 62,000 254.00 190.50 H

62,001 – 63,000 276.00 207.00 I

63,001 – 64,000 298.00 223.50 J

64,001 – 65,000 320.00 240.00 K

65,001 – 66,000 342.00 256.50 L

66,001 – 67,000 364.00 273.00 M

67,001 – 68,000 386.00 289.50 N

68,001 – 69,000 408.00 306.00 O

69,001 – 70,000 430.00 322.50 P

70,001 – 71,000 452.00 339.00 Q

71,001 – 72,000 474.00 355.50 R

72,001 – 73,000 496.00 372.00 S

73,001 – 74,000 518.00 388.50 T

74,001 – 75,000 540.00 405.00 U

Over 75,000 550.00 412.50 V

Tax-Suspended Vehicles

(See Part II on page 4 of

the instructions.)

W

* See page 7 of the instructions for information on logging and Canadian/Mexican vehicles.

Totals. Add the number of vehicles in columns (3a) and (3b). Enter the total

here and on Schedule 1, Part III, line a. Add the amounts in column (4). Enter

the total here and on Form 2290, line 2

Form 2290 (Rev. 7-2003) Page 2

Complete both copies of Schedule 1 (Form 2290) and attach them to Form 2290.

$$ $

$

Form 2290 (Rev. 7-2003)

Category

A

B

C

D

E

F

G

H

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SCHEDULE 1

(Form 2290)

OMB No. 1545-0143 (Rev. July 2003)

Department of the Treasury

Internal Revenue Service

FOR IRS

USE ONLY

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FF

FP

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Vehicles on Which You Are Reporting Tax. See page 4 of the instructions.

Vehicle Identification Number Category Vehicle Identification Number Category

1 7

2 8

3 9

Vehicles for Which Tax Is Suspended—5,000 Miles or Less (7,500 Miles or Less for Agricultural

Vehicles). See page 4 of the instructions.

Vehicle Identification Number Category Vehicle Identification Number Category

1 W 2 W

4 10

Summary of Reported Vehicles

Enter the number of taxable vehicles from Form 2290, page 2, column 3, Totals a

Enter the total number of taxable vehicles on which the tax is suspended from Form 2290, page 2, column 3 (category W) b

For Privacy Act and Paperwork Reduction Act Notice, see page 7 of the instructions.

SCHEDULE 1 Schedule of Heavy Highway Vehicles (Form 2290) For the period July 1, 2003, through June 30, 2004 OMB No. 1545-0143 (Rev. July 2003)

Vehicles on Which You Are Reporting Tax. See page 4 of the instructions.

Vehicle Identification Number Category Vehicle Identification Number Category

1 7

2 8

3 9

Vehicles for Which Tax Is Suspended—5,000 Miles or Less (7,500 Miles or Less for Agricultural

Vehicles). See page 4 of the instructions.

Vehicle Identification Number Category Vehicle Identification Number Category

1 W 2 W

4 10

Summary of Reported Vehicles

a Enter the number of taxable vehicles from Form 2290, page 2, column 3, Totals

b Enter the total number of taxable vehicles on which the tax is suspended from Form 2290, page 2, column 3 (category W)

For Privacy Act and Paperwork Reduction Act Notice, see page 7 of the instructions.

This copy will be stamped and returned to you for use as proof of payment when registering

vehicle(s) with a state.

Part III

Part I

Part II

Part III

Part I

Part II

Department of the Treasury

Internal Revenue Service

Name as shown on Form 2290 Employer identification number

Type

or

Print

Address (number, street, and room or suite no.)

City, state, and ZIP code (For Canadian or Mexican address, see page 3 of the instructions.)

Name as shown on Form 2290 Employer identification number

Type

or

Print

Address (number, street, and room or suite no.)

Do not cut or separate the forms on this page.

a

b

a

b

Schedule of Heavy Highway Vehicles

For the period July 1, 2003, through June 30, 2004

Complete both copies of Schedule 1 and attach them to Form 2290.

City, state, and ZIP code (For Canadian or Mexican address, see page 3 of the instructions.)

Caution: You must list all vehicles. Attach a separate list if needed.

Caution: You must list all vehicles. Attach a separate list if needed.

5 11

6 12

5 11

6 12

Schedule 1 (Form 2290) (Rev. 7-2003)

Schedule 1 (Form 2290) (Rev. 7-2003)