Form 102-Td - Schedule 15b - Terminal Operator Schedule Of Disbursements
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1Michigan Department of Treasury
102-TD
3781 (Rev. 9-06)
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Schedule 15B - Terminal Operator Schedule of Disbursements
This form is issued under authority of P.A. 403 of 2000, as amended.
Use a separate schedule for each product code.
Product Code (see instructions on page 2)
Terminal Operator Name
Account Number (FEIN or TR)
License Number
Terminal Control Number
Report Period (MM/YYYY)
Report Whole Gallons Only
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
Carrier/Transporter
Position Holder/Receiving Exchange Partner
Dest.
Date
Shipping Document/
Net
Gross
Name
FEIN
Mode
State
Name
FEIN
Removed
Ticket Number
Gallons
Gallons
TOTALS
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Parent category: Financial