PT-101.3 (3/01) (back)
Name of distributor
FEIN
Month/year
Submit in duplicate. Use a separate sheet for each state and province. To the state or province of:
Part II — Sales to customers outside New York State
Mode
Carrier’s name
Purchaser’s name
City and state, point of:
Date
of
and
and
Gallons
shipped
delivery
FEIN
FEIN
sold
Origin
Destination
Total gallons (enter here and on Form PT-101, line 11)
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