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Form Rev-1096b Mf - Liquid Fuels And Fuels Tax Report Receipts And Disbursements Summary - 2013 Page 2

INSTRUCTIONS FOR THE COMPLETION OF LIQUID FUELS

AND FUELS TAX REPORT (REV-1096B)

In accordance with the Federal Privacy Act, the Social Security/Employer Identification Number(s) herein

requested is required pursuant to 75 Pa.C.S. § 9003(b), and will be used to establish distributor identity and

conduct internal auditing functions. Such numbers may be divulged for official purposes.

RECEIPTS AND DISBURSEMENTS SUMMARY

SECTION I - RECEIPTS (FOR EACH FUEL CATEGORY SHOW THE FOLLOWING):

Line:

Schedule:

N/A

Gallons placed into marketing division from PA refinery production.

Gallons received from PA non-registered distributors (tax paid) and placed in

inventory.

Gallons received (PA tax paid) and direct shipped to customers.

Gallons received tax-free from PA registered distributors (Resales) and placed in

inventory.

Gallons received tax-free and direct shipped to customers.

Gallons imported and direct shipped to PA customers.

Gallons imported from another state and placed into your own storage.

N/A

Total Receipts (Section I - Sum of Lines 1 through 7).

SECTION II - DISBURSEMENTS (FOR EACH FUEL CATEGORY SHOW THE FOLLOWING):

Gallons delivered tax collected (taxable sales).

Gallons used (taxable use) on which tax is being remitted.

Gallons delivered to PA registered distributors (resales) tax free.

Gallons exported from Pennsylvania. Provide separate duplicate schedules for

each state into which product was shipped.

Gallons delivered tax-exempt to the U.S. Government, American Red Cross,

Department of Defense, Civil Air Patrol, etc. (BULK SALES ONLY)

Gallons delivered to the Commonwealth of Pennsylvania and its political subdivisions

(e.g., Cities, Counties, Townships, Boroughs, Second Class County Authorities,

etc.). (BULK SALES ONLY)

Gallons delivered to other exempt entities (e.g., Volunteer Fire, Rescue and

Ambulance Services; Non-Profit Non-Public Schools (K-12); and Electric

Cooperative). (BULK SALES ONLY)

N/A

Total Disbursements (Section II - Sum of Lines 1 through 7).

Form Rev-1096b Mf - Liquid Fuels And Fuels Tax Report Receipts And Disbursements Summary - 2013 Page 2