Form Mvf-3 - Terminal Operator'S Monthly Gasoline Activity Schedule Page 2
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4State of Connecticut
Form MVF-3 (Rev. 02/17)
Terminal Operator’s Monthly Gasoline Activity Schedule
Department of Revenue Services
Name of terminal operator
Terminal operator Connecticut Tax Registration Number
Month of
Address of terminal operator
Telephone number
Customer name
Customer Connecticut Tax Registration No.
Part 2 - Receipts (continued)
Receipts
Type of Gasoline by Gross Gallons
Name of
Date of Delivery
Method of Delivery
Transporter or Vessel
Unleaded Regular
Unleaded Mid-Grade
Unleaded Premium
Total Gross Gallons
Totals (Transfer to Page 1, Part 2)
Page 2 of 4
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