Form 3780 (Schedule 15a) - Terminal Operator Schedule Of Receipts - Michigan Terminals Only

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Michigan Department of Treasury
101-TR
3780 (Rev. 9-06)
Schedule 15A - Terminal Operator Schedule of Receipts - Michigan Terminals Only
This form is issued under authority of P.A. 403 of 2000, as amended.
Use a separate sheet for each Position Holder, or sort and calculate subtotal
for each Position Holder. Use a separate schedule for each product code.
Product Code (see instructions on page 2)
Terminal Operator Name
Account Number (FEIN or TR)
Terminal Control Number
Report Period (MM/YYYY)
Report Whole
Gallons Only
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
Carrier
Carrier
Date
Shipping Document/
Net
Position Holder
Gross
Name
FEIN
Mode
Name
FEIN
Received
Ticket Number
Gallons
Gallons
Totals

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