Schedule AU-750
Department of Revenue Services
Report for month ending
State of Connecticut
Monthly Report of Motor Fuel Carrier
Excise Taxes Unit
CT Tax Registration Number
25 Sigourney St Ste 2
Export or Import Schedule of Petroleum Products
Hartford CT 06106-5032
(Rev. 09/10)
Federal Employer ID Number (FEIN), or
Social Security Number (SSN)
Due on or before
1. Date of shipment
2. Type of product loaded
3. Date of delivery
4. Gallons
5. Name of boat, barge, or
vessel
6. Loading terminal name
7. Loading terminal address
8. Loading terminal TCN
9. Consignor name
10. Consignor address
11. Consignee name
12. Consignee address (actual delivery point)
13. Receiving terminal
TCN
14. Original consignee name
15. Manner of delivery
1. Date of shipment
2. Type of product loaded
3. Date of delivery
4. Gallons
5. Name of boat, barge, or
vessel
6. Loading terminal name
7. Loading terminal address
8. Loading terminal TCN
9. Consignor name
10. Consignor address
11. Consignee name
12. Consignee address (actual delivery point)
13. Receiving terminal
TCN
14. Original consignee name
15. Manner of delivery
1. Date of shipment
2. Type of product loaded
3. Date of delivery
4. Gallons
5. Name of boat, barge, or
vessel
6. Loading terminal name
7. Loading terminal address
8. Loading terminal TCN
9. Consignor name
10. Consignor address
11. Consignee name
12. Consignee address (actual delivery point)
13. Receiving terminal
TCN
14. Original consignee name
15. Manner of delivery
Declaration: I declare under penalty of law that I have examined this report (including any accompanying schedules and statements) and, to the best of
my knowledge and belief, it is true, complete, and correct. I understand the penalty for willfully delivering a false report or document to the Department of
Revenue Services (DRS) is a fine of not more than $5,000, or imprisonment for not more than five years, or both. The declaration of a paid preparer other
than the taxpayer is based on all information of which the preparer has any knowledge.
Taxpayer signature
Title
Date
Paid preparer signature
Telephone number
Date
Print preparer name
Preparer’s address
Preparer’s SSN, PTIN or FEIN
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