Form Pt-101.1 - Motor Fuel Receipts Page 2

PT-101.1 (3/01) (back)

Name of distributor

FEIN

Month/year

Part II — Receipts from sources located within this state

Column A

Column B

Mode

Carrier’s name

Seller’s name

Purchaser’s name

City and state, point of:

Date

of

and

and

and

Gallons purchased on

received

delivery

FEIN

FEIN

FEIN

which the tax has been

All other

Origin

Destination

passed through to you

gallons

1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2

1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2

1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2

1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2

1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2

1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2

1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2

Column A total gallons

( enter here and include in the amount on Form PT-101, line 22) .....................................................................................

1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2

Column B total gallons ...........................................................................................................................................................................................................

Total gallons (add Columns A and B; enter here and on Form PT-101, line 3, Columns A and B) ..................................................................................................