Form Mf-002 - Wisconsin Combined Monthly Fuel Summary Report Page 4
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4Section 3: Carrier Report
NO ACTIVITY
Column 1
Column 2
Column 3
Fuel Transported (Sch PD)
Gasoline
Undyed Diesel
Other Fuels
1 Enter total product transported in Gross Gallons . . . . . . . . . . . . . . . . . . . . . . . .
1
2 Enter total product transported in Net Gallons . . . . . . . . . . . . . . . . . . . . . . . . . .
2
Section 4: Terminal Operators Report
NO ACTIVITY
Column 1
Column 2
Column 3
Fuel Transported in Net Gallons
Gasoline
Undyed Diesel
Other Fuels
1 Fuel delivered to IRS Registered Terminals (Sch. TR). . . . . . . . . . . . . . . . . . . .
1
2 Fuel originating from IRS Registered Terminals (Sch. TD) . . . . . . . . . . . . . . . .
2
Section 5: Terminal Ending Inventory
Column 1
Column 2
Column 3
Column 4
EOM Inventory (net gallons)
IRS Terminal Code
Product Code
Date
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DECLARATION: I declare under penalties of law that the above information is true, correct, and complete to the best of my knowledge and belief.
Contact Person (please print clearly)
Telephone Number
Signature
Date
(
)
4
MF-002 (R. 10-13)
Wisconsin Department of Revenue
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