Form Cc-2 - Monthly Common And Contract Petroleum Product'S Carrier Report
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1CC-2
Rev. 4/04
P.O. Box 530
Columbus, OH 43216-0530
Monthly Common and Contract Petroleum Product’s Carrier Report
Complete and attach enclosed schedules
Carrier name
FEIN
Month/Year
Street
City
State
ZIP
Check here if new address
1. Total gallons of petroleum product loaded at an Ohio terminal or bulk plant and delivered
to another state (attach Schedule 1A) ..................................................................................
2. Total gallons of petroleum product loaded at an out-of-state terminal or bulk plant facility
and delivered in Ohio (attach Schedule 2A) .........................................................................
3. Total gallons of petroleum product loaded at an Ohio terminal or bulk plant and delivered
in Ohio (attach Schedule 3A) ...............................................................................................
4. Total gallons petroleum product transported (total of lines 1 through 3) ...................
I declare under penalties of perjury that this report (including any accompanying schedules and statements) has been
examined by me and to the best of my knowledge and belief is a true, correct, and complete report.
Authorized signature
Title
Telephone number
Date
This report must be fi led with the Ohio Department of Taxation, Motor Fuel Tax Compliance Unit, P.O. Box 530, Columbus,
OH 43216-0530 on or before the last day of each month following the report period. Telephone inquiries (614) 466-3503;
Fax (614) 752-8644.
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