Form 3715 - Carrier'S Monthly Report - Pipeline, Barge, Marine Vessel
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3Michigan Department of Treasury
Reset Form
200-CCR
3715 (Rev. 09-12)
Carrier's Monthly Report: Pipeline, Barge, Marine Vessel
This form is issued under authority of P.A. 403 of 2000, as amended.
This report is due
2. Account Number (FEIN or TR)
2A. License Number
3. Report Period (MM/YYYY)
1. Company Name and Mailing Address
4. Contact Person Name
5. Telephone Number
6. Fax Number
7. E-mail Address
Net Gallons - Report Whole Gallons Only
This report must be filed by all carriers for
Column 6
Column 1
Column 2
Column 3
Column 4
Column 5
shipments into, out of and within the State of
Michigan.
Gasoline
Aviation
Other Products
Jet Fuel
Undyed
Dyed
Gasoline
See page 2 for instructions.
Diesel Fuel
Diesel Fuel
8. Total gallons of petroleum product
transported from Michigan to another state.
Enter total from attached Schedule(s) 14A.
9. Total gallons of petroleum product
transported from out-of-state terminals and
refineries into Michigan. Enter total from
attached Schedule(s) 14B.
10. Total gallons of petroleum product
transported from Michigan terminals and
refineries to locations elsewhere in
Michigan. Enter total from attached
Schedule(s) 14C.
11. Total gallons of petroleum product
transported. Add lines 8 through 10.
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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