Form 3716 - Terminal Operator Monthly Report

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Michigan Department of Treasury
100-TOR
3716 (Rev. 09-12)
This form is issued under authority of P.A. 403 of 2000, as amended. Filing is mandatory.
Terminal Operator Monthly Report
This report is due
3. Report Period (MM/YYYY)
2. Account Number (FEIN or TR)
2A. License Number
1. Company Name and Mailing Address
4. Contact Person Name
5. Telephone Number
6. Fax Number
7. E-mail Address
    
8. Terminal Control Number (TCN)
9. Location of Terminal (City and State)
This report must be filed by all terminal
operators. A separate report and
Net Gallons - Report Whole Gallons Only
schedules must be filed for each IRS-
Gasoline
Ethanol
Aviation
Undyed
Undyed
Dyed
Other
approved terminal.
Blends
Gasoline
Jet Fuel
Petroleum
Biodiesel
Diesel Fuel
Products
See page 2 for instructions.
E70 - E99
B05 or higher
Diesel
10. Beginning Inventory (Michigan terminals only).
    
11. Total Receipts (Schedule 15A)
    
(Michigan terminals only).
12. Total Gallons Available. (Michigan terminals
    
only) Add lines 10 and 11.
13. Total Disbursements (Schedule 15B).
    
14. Computed Ending Inventory (Michigan terminals
    
only). Subtract line 13 from line 12.
15. Actual Physical Ending Inventory
    
(Michigan terminals only).
16. Gains & Losses. (Losses need to be reported
    
with parenthesis around the loss) (Michigan
terminals only) Subtract line 14 from line 15.
I declare, under penalty of perjury, that the information in this report and attachments is true and complete to the best of my knowledge.
    
I authorize Treasury to discuss my return and attachments with my preparer.
Do not discuss my return with my preparer.
    
Authorized Signature
Signature of Preparer
Preparer FEIN
Printed Name
Date
Printed Name
Date
Title
Telephone Number
Address
Telephone Number
MAIL REPORT TO: Michigan Department of Treasury, P.O. Box 30474, Lansing, Michigan 48909-7974.
Questions ? - Please call (517) 636-4600

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