Form 72a178 - Distributor'S Schedule Of Disbursements
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272A178 (7-07)
Distributor’s Schedule of Disbursements
Commonwealth of Kentucky
DEPARTMENT OF REVENUE
Company Name
Product Code (See
License Number
FEIN
Report Period MM/YY
instructions on page 2)
Schedule Type (Check appropriate box. See page 2 for schedule descriptions. Do not combine schedule types or product codes.
10A.
10G.
10I.
10J.
10Y.
5.
5D.
6.
7.
8.
9.
10.
Instructions: This form must be completed by all licensed motor fuels dealers for disbursements.
(4) Point of
(1)
(2)
(3)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)
Carrier
Carrier
Mode
Terminal
Sold
Purchaser’s
Date
Document
Net
Gross
Origin
Destination
Name
FEIN
Code
To
FEIN or ID #
Shipped
Number
Gallons
Gallons
N/A
Total
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Parent category: Financial