Form Pt-101.3 - Nontaxable Sales Of Motor Fuel Page 3

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PT-101.3 (9/06) Page 3 of 3
Name of distributor
FEIN
Month/year
Part 5 — Aviation gasoline use, storage, or sales to retail sellers of aviation gasoline
(see instructions)
Date
Mode of
Carrier’s name
Purchaser’s name
Origin
Destination
Manifest
Gallons
Product
sold
delivery
and FEIN
and FEIN
number
code*
(city, state)
(city, state)
Number of gallons of aviation gasoline being imported into this state as a registered retail seller of aviation gasoline .................................................................
Number of gallons of aviation gasoline being imported into this state for self-use as an airline ....................................................................................................
Total gallons
........................................................................................................................................................................
(enter here and on Form PT‑101, line 18)
Part 6 — Sales of E85 to filling stations
Date
Mode of
Carrier’s name
Purchaser’s name
Origin
Destination
Manifest
Gallons
sold
delivery
and FEIN
and FEIN
terminal control
terminal control
number
number or
number or
(city, state)
(city, state)
Total gallons
........................................................................................................................................................................
(enter here and on Form PT‑101, line 19)
*From Publication 902, Product Codes for Fuels.

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