Form L-2122 - Supplier Schedule Of User Fee-Paid Receipts (Page 2 of 2) in pdf

Form L-2122 - Supplier Schedule Of User Fee-Paid Receipts Page 2

INSTRUCTIONS FOR L-2122

SUPPLIER SCHEDULE OF USER FEE PAID PURCHASES

GENERAL INFORMATION - Use this schedule to report user fee paid purchases from other suppliers. Prepare a

schedule for each product type listed in order by supplier.

COLUMN 1 & 2 - CARRIER

Enter the name of the company that transported the product from the terminal and the federal identification

number if available.

COLUMN 3 - MODE OF TRANSPORT

Enter the mode of transport from the terminal. Use on of the following:

= Truck

R = Rail

B = Barge

= Ship

PL = Pipeline

BA = Book Adjustment

ST = Stock Transfer

COLUMN 4 - POINT OF ORIGIN/DESTINATION

Enter the name of the state of origin and destination (abbreviations are acceptable).

COLUMN 5 & 6 - SUPPLIER

Enter the name of the company that sold the product and the federal identification number if available.

COLUMN 7 - DATE RECEIVED

Enter the date the product was shipped from the terminal.

COLUMN 8 - DOCUMENT NUMBER

Enter the identifying number from the document issued at the terminal where the product was removed over

the rack.

COLUMN 9 - NET GALLONS

Enter the net amount of gallons withdrawn from the terminal.

COLUMN 10 - GROSS GALLONS

Enter the gross amount of gallons withdrawn from the terminal.

COLUMN 11 - BILLED GALLONS

Enter the number of gallons billed to you. (Should be the same as either the net gallons or gross gallons.) The

total from Column 11 will be the amount you need to enter on Line 2 of L-2119.

44771012

L-2122 I

(Rev. 9/8/11)

4477

Form L-2122 - Supplier Schedule Of User Fee-Paid Receipts Page 2