FORM
Nebraska Motor Fuels Terminal Operator Schedule of Disbursements
87
Page ____ of ____
Name as Shown on Report
Terminal Code
Terminal Code
Federal Employer Identification Number
Nebraska Identification Number
Reporting Month/Year
Reporting Month/Year
PRODUCT CODES – Check Only One
061 Nat. Gasoline (Denaturant)
130 Aviation Jet Fuel
B00 Undyed Biodiesel
065 Gasoline
142 Kerosene
D00 Dyed Biodiesel
123 or E00 Ethanol-Alcohol
160 Undyed Diesel
170 or B01-B99 Undyed Biodiesel Blend
124 or E01-E99 Gasohol
228 Dyed Diesel
171 or D01-D99 Dyed Biodiesel Blend
125 Aviation Gasoline
(6)
(8)
(2)
(4)
(10)
(5)
(7)
(9)
(1)
(3)
Position Holder
Bill of Lading/
Carrier
Destination
Gross
Position Holder
Date
NG
Carrier Name
Mode
FEIN
Manifest No.
FEIN
State
Name
Gallons
• Must be Filed With Your Terminal Report