Form Pt-101.1 - Motor Fuel Receipts

PT-101.1

New York State Department of Taxation and Finance

Motor Fuel Receipts

(9/06)

Read instructions (Form PT-101-I) carefully. Keep a copy of this completed form for your records.

Name of distributor

FEIN

Month/year

Part 1 — Receipts from sources located outside this state

B

Date

Mode of

Carrier’s name

Seller’s name

Origin

Destination

A

Product

received

delivery

and FEIN

and FEIN

terminal control

terminal control

All other gallons

code*

Gallons purchased

number or

number or

on which the tax

has been passed

(city, state)

(city, state)

through to you

Column A total gallons

............................................................................................

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

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

Total gallons

...............................................................................................................

(add Columns A and B; enter here and on Form PT-101, line 2, Columns A and B)

*From Publication 902, Product Codes for Fuels.