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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