Form 3779 - Transporter Schedule Of Deliveries Of Diversions

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Michigan Department of Treasury

3779 (Rev. 9-06)

Transporter Schedule of Deliveries or Diversions (803-TS)

Product Code (see instructions on Page 2)

This form is issued under authority of P.A. 403 of 2000, as amended.

Company Name

Account Number (FEIN or TR)

License Number

Report Period (MM/YYYY)

CHECK ONE box below to identify what is itemized on this schedule. Do not combine schedule types or product codes.

Schedule 11A - Gallons diverted TO Michigan Original Point of Destination must be entered in Column 8.

Schedule 11B - Gallons Diverted FROM Michigan Revised Point of Destination must be entered in Column 8.

Schedule 14A - Deliveries of petroleum product loaded in Michigan and transported to locations outside of Michigan (Exports).

Schedule 14B - Deliveries of petroleum product loaded at out-of-state bulk plants, terminals and/or refineries, and transported into Michigan (Imports).

(8)

(3)

(4)

(5)

(6)

(1)

(2)

(7)

(9)

(10)

(11)

(12)