Michigan Department of Treasury
3778 (Rev. 09-12)
Reason for 3-day Payment (see General Information on Page 2)
Three Day Payment Voucher
Import from outside the United States
Issued under authority of P.A. 403 of 2000, as amended. Filing is mandatory.
Diversion requiring 3-day payment
Company Name
Account Number (FEIN or TR)
DBA
Contact Person Name
Address (Street, RR#, P.O. Box)
Telephone Number
Fax Number
City, State, ZIP
E-mail Address
IMPORT/DIVERSION INFORMATION
Date Import Entered Michigan
Document Number
Import Verification/Diversion Number
Date Verification Number Assigned
Enter Product Name, Codes and Gallons. See page 2 for instructions, product classification and codes.
Gasoline Products
Product Codes
Gallons
Tax Rate
Calculated Tax Due
1.
1.
Gasoline
065
x .19
2.
2.
Product Name
x .19
Ethanol Products E70 - E99
3.
3.
E____
x .19
3.
Product Name
Undyed Diesel Products (see instructions on page 2)
x .15
4.
Undyed Diesel
160
4.
x .15
Product Name
5.
5.
Undyed Biodiesel Products B05 - B00
x .15
B____
Product Name
6.
6.
Dyed Diesel Products (dyed to U.S. Standards)
7.
228
Dyed Diesel
7.
x .00
Dyed Biodiesel
D____
8.
Product Name
x .00
8.
Aviation Products
9.
9.
Aviation Fuel
125
x .03
10.
10.
Jet Fuel
130
x .03
Miscellaneous
x ____
11.
11.
Product Name
Tax Calculation
12. Total Tax Due. Add lines 1 through 11
12.
13. Penalty for late filing (100%). Enter amount from line 12
13.
14. Interest. (1% above prime rate set January 1 and July 1 of each year)
14.
15. TOTAL REMITTANCE. Add lines 12, 13 and 14
15.
Under penalty of perjury, I declare that I have examined this voucher, and to the best of my knowledge and belief, it is correct and complete.
Authorized Signature
Signature of Preparer
I authorize Treasury to discuss my return and attachments with my preparer.
Do not discuss my return with my preparer.
Printed Name
Printed Name
Preparer FEIN
Title
Address
Telephone Number
Date
Telephone Number
Date
Questions ???? - Please call (517) 636-4600. Make check payable to "State of Michigan-Special Taxes." Print your account number on
the front of your check. MAIL WITH REMITTANCE TO: Michigan Department of Treasury, Special Taxes Division, P.O. Box 30474,
Lansing, MI 48909-7974.