Form Pt-101.1 - Motor Fuel Receipts Page 2

PT-101.1 (9/06) (back)

Name of distributor

FEIN

Month/year

Part 2 — Receipts from sources located within this state

Date

Mode of

Carrier’s name

Seller’s name

Origin

Destination

B

Product

A

received

delivery

and FEIN

and FEIN

terminal control

terminal control

Gallons purchased

All other gallons

code*

number or

number or

on which the tax

has been passed

(city, state)

(city, state)

through to you

Column A total gallons

............................................................................................

(enter here and include in the amount on Form PT-101, line 22)

Column B total gallons ....................................................................................................................................................................................................................

Total gallons

...............................................................................................................

(add Columns A and B; enter here and on Form PT-101, line 3, Columns A and B)

*From Publication 902, Product Codes for Fuels.