Form Mf-3a - Gasohol Receipts Schedule - 2000
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1MF-3A
STATE OF CONNECTICUT
DEPARTMENT OF REVENUE SERVICES
Gasohol Receipts Schedule
(REV.12/00)
Month of
INSTRUCTIONS
The purpose of this schedule is to provide
Use this schedule to complete Lines 2,
information on your purchases of gasohol.
3, 4, and 5 on Form O-MF3,
Gasohol Tax Return .
Schedule Number
Name of Licensed Distributor
Prepare a separate schedule for each
schedule required.
Connecticut Tax Registration Number
Title of Schedule
Insert schedule number and title in the
spaces provided.
Type
Point of
Whole Gallons
o f
Connecticut
Connecticut
Date
Name of Supplier
Method of Delivery
Shipment
Delivery
Product *
Tax Paid
Tax Not Paid
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
TOTAL GALLONS
(Transfer this total to the appropriate line on Form O-MF3, Gasohol Tax Return. )
* Indicate type of product; for example, gasoline, gasohol, ethanol, methanol or gasoline additives.
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