Form Ga-Ix - Motor Fuel Tax Importer Report Page 2

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Reverse Side GA-IX

(Rev. 6-01)

STATE OF NEW JERSEY

Name of Licensee __________________________________________________________________________________________________________________________________________________

Report Month _____________________ , 20____

(This section to be used if required)

Date

Line

Rec’d

Method of Delivery

Purchased From

Point of Shipment

Sold To

Point of Delivery

Gallons

22.

23.

24.

25.

26.

27.

28.

29.

30.

31.

32.

33.

34.

35.

36. Sub-total Gallons Imported . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

(Transfer sub-total on Line 36 to Line 8 on front side of this form).