Form 4124 - Blender Schedule Of Disbursements

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Michigan Department of Treasury
4124 (8-08)
Blender 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.
DRAFT
11/17/03
Company Name
Account Number (FEIN or TR)
License Number
Report Period (MM/YYYY)
Schedule Types: Check the appropriate box. See page 2 for schedule descriptions. Do not combine schedule types or product codes.
5
5C
5F
5Z
If export schedule (Schedule 7A or 7B) indicate destination State/Province/Country: _________________________
6F
6Z
7A
7B
A separate schedule must be filed for each state/province/country.
8
9
10F
10G
Report Whole Gallons Only
10M
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)
Point of
Sold To Purchaser
Date
Document
Gallons
Carrier Name
Carrier FEIN
Mode
Origin
Dest.
Shipped
Number
Net
Gross
Billed
Name
FEIN
TOTALS

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