Fillable Form Omf-11 - Terminal Operator Report printable pdf download

Form Omf-11 - Terminal Operator Report

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Division use only - DLN Stamp

Division use only Date Stamp

Month

Year

Due Date:

Mail with Report to:

New Jersey Division of

On or before the 25th day

Taxation, PO Box 189,

of the month following the

Trenton, NJ, 08695-0189

report month.

Pursuant to NJSA 54:39-11et seq

10/1/10

TERMINAL OPERATOR REPORT

OMF-11

FID#

TERMINAL NUMBER

NAME OF OPERATOR

NAME OF TERMINAL

ADDRESS - NUMBER & STREET

LOCATION OF TERMINAL

CITY

STATE

ZIP CODE

CITY

STATE

ZIP CODE

P.C.

1. Fuel in Inventory Beginning of Month

2. Total Fuel Received During the Month

Total Fuel Available (line 1 plus line 2)

4. Total Fuel Disbursements During the Month

5. Ending Inventory (line 3 minus line 4)

Total Fuel Accounted for (line 4 plus line 5)

7. Gain or Loss (line 3 minus line 6)

8. Actual Physical Ending Inventory

I declare under penalties provided by the law that all the information contained in this return and in all schedules and statements in support of it is true and accurate in every particular.

Title

Date

Signature of authorized Officer of Taxpayer

Federal Identification Number

Date

Signature of Individual or Firm Preparing Return