Form 3749 - Importer Schedule Of Disbursements
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Michigan Department of Treasury
402-XD
3749 (Rev. 8-08)
Importer Schedule of Disbursements
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. Do not combine schedule or product types.
5
5C
5F
5Z
6F
6Z
8
9
10G
10M
Report Whole Gallons Only
(4)
(5)
(6)
(9)
(10)
(11)
(7)
(8)
(1)
(2)
(3)
Point of
Sold To/Purchaser
Gallons
Date
Document
Carrier Name
Carrier FEIN
Mode
Shipped
Number
Origin
Dest.
Name
FEIN
Net
Gross
Billed
TOTALS
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Parent category: Financial