Form Pt-101.3 - Nontaxable Sales Of Motor Fuel Page 2
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2
3Page 2 of 3 PT-101.3 (9/06)
Name of distributor
FEIN
Month/year
Part 4 — Sales to exempt hospitals and other nontaxable distributions
Section A — Sales to exempt hospitals included in the organizations described in Section 1116(a)(4) of the Tax Law
Date
Mode of
Carrier’s name
Purchaser’s name
Origin
Destination
Purchaser’s
Gallons
Product
sold
delivery
and FEIN
and FEIN
exempt number
code*
(city, state)
(city, state)
Subtotal — Sales to exempt hospitals............................................................................................................................................................................................
Section B — Other nontaxable distributions
Date
Mode of
Carrier’s name
Purchaser’s name
Origin
Destination
Purchaser’s
Gallons
Product
sold
delivery
and FEIN
and FEIN
code*
(city, state)
(city, state)
(city, state)
Subtotal — Other nontaxable distribution ......................................................................................................................................................................................
Total gallons — Add Sections A and B subtotals
.................................................................................................................
(enter here and on Form PT‑101, line 17)
*From Publication 902, Product Codes for Fuels.
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