Form 4004 - Exporter Quarterly Report
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3Michigan Department of Treasury
540-EXP
Reset Form
4004 (Rev. 09-12)
Exporter Quarterly Report
Issued under authority of P.A. 403 of 2000, as amended. Filing is mandatory.
This report is due
2A. License Number
2. Account Number (FEIN or TR)
3. Report Period (MM/YYYY)
1. Company Name and Mailing Address
4. Contact Person Name
6. Fax Number
5. Telephone Number
7. E-mail Address
Enter the total gross gallons reported on Schedules 7A and 7B for each product type.
2. Dyed
3. Undyed
4. Aviation
6. Other
1. Gasoline
5. Jet Fuel
Schedule
Diesel
Diesel
Gasoline
Products
8. Total gallons exported,
7A
destination state tax paid
9. Total gallons exported,
7B
Michigan tax paid
CERTIFICATION
I declare, under penalty of perjury, that the information in this report and attachments is true and complete to the best of my knowledge.
I authorize Treasury to discuss my return and attachments with my preparer.
Do not discuss my return with my preparer.
Authorized Signature
Preparer Signature
Date
Date
Printed Name
Printed Name
Preparer FEIN
Title
Telephone Number
Address
Telephone Number
Mail Report to:
Michigan Department of Treasury
P.O. Box 30474
Lansing, MI 48909-7974
Questions: Call (517) 636-4600
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