Form 3817 - Blender Schedule Of Receipts

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Michigan Department of Treasury
3817 (Rev. 9-06)
Blender Schedule of Receipts
Product Code (see instructions on Page 2)
This form is issued under authority of P.A. 403 of 2000, as amended. Filing is mandatory.
Company Name
Account Number (FEIN or TR)
License Number
Report Period (MM/YYYY)
Schedule Types: Check the appropriate box. See page 2 for schedule descriptions. Do not combine schedule types or product codes.
1
2B
Report Whole Gallons Only
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
Gallons
Point of
Purchased or Acquired from Supply Source
Date
Document
Carrier Name
Carrier FEIN
Mode
Shipped
Number
N/A
Origin
Destination
Name
FEIN
Net
Gross
TOTAL

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Parent category: Financial
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