Form Pt-102.1 - Diesel Motor Fuel Receipts Page 2

PT-102.1 (1/07) (back)

Name of distributor

FEIN

Month/year

Part 2 — Receipts in New York State from sources located within this state

A

B

Date

Mode of

Carrier’s name

Seller’s name

Origin

Destination

Product

received

delivery

and FEIN

and FEIN

terminal control

terminal control

Gallons purchased

All other gallons

code*

number or

number or

on which the taxes

have been passed

(city, state)

(city, state)

through to you

Totals .................................................................................................................................................................................................................

Total gallons

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

(add columns A and B totals; enter here and on Form PT‑102, line 3)

*From Publication 902, Product Codes for Fuels.