Form 3769 - Retail Marine Diesel Dealer Return

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Michigan Department of Treasury
3769 (Rev. 09-12)
620-MRN
Retail Marine Diesel Dealer Return
This report is due
1. Company Name and Mailing Address
2. Report Period (MM/DD/YYYY)
3. Account Number (FEIN or TR)
3A. License Number
4. Contact Person Name
5. Telephone Number
6. Fax Number
7. E-mail Address
INSTRUCTIONS: All licensed marine diesel dealers must file this report with remittance on or before the 20th day of the month follow-
ing the end of the reporting period. Please only report whole gallons. File even if no tax is due. Failure to file is punishable by penalty,
interest and revocation of your license. Complete all applicable items. See page 2 for line-by-line instructions.
Undyed Biodiesel
Dyed Diesel
Dyed Biodiesel
PART 1: REPORTABLE INFORMATION
SCHD
Undyed Diesel
(B05 or higher)
Fuel
(D05 or higher)
8. Total gallons of undyed fuel sold for marine purposes .........
9. Total gallons of dyed fuel sold for marine purposes .............
10. Total gallons of dyed fuel sold for untaxed marine use ........
6F
11. Total gallons of dyed fuel sold for taxable purposes ............
PART 2: CREDITS - UNDYED FUEL ONLY
12. Tax paid gallons included in Line 8 ......................................
13. Gallons sold tax-free to the Federal Government ................
8
14. Gallons sold tax-free to State and Local Government .........
9
15. Gallons sold tax-free for nontaxable use..............................
16. Total gallons for undyed fuel (Add Lines 12-15) ...................
17. Subtract line 16 from line 8 ..................................................
18. TAX RATE ............................................................................
.15
.15
.15
.15
PART 3: TAX CALCULATION
19. Multiply Line 17 by Line 18 (undyed only) ............................
20. Multiply Line 11 by Line 18 (dyed fuel only) .........................
21. Total Tax Due: Add Lines 19 and 20 .....................................
22. Penalty .................................................................................
23. Interest .................................................................................
24. Total Remittance (Add Lines 21 through 23) ........................
CERTIFICATION
I certify under penalty of perjury, that I have examined this return, and to the best of my knowledge and belief, it is true and complete.
I authorize Treasury to discuss my return and attachments with my preparer.
Do not discuss my return with my preparer.
Authorized Signature
Printed Name
Date
Title
Telephone Number
Preparer’s Signature
Preparer’s FEIN
Printed Name
Date
Telephone
Address
Call (517) 636-4600 with questions. Make check payable to “State of Michigan-Motor Fuel”. Print your account number on the front of your check. MAIL
WITH REMITTANCE TO: Michigan Department of Treasury, P.O. Box 77401, Detroit, Michigan 48278. MAIL REFUND REQUEST OR ZERO RETURN
TO: Michigan Department of Treasury, P.O. Box 30474, Lansing, Michigan 48909-7974

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