Form Pet 380 - Unlicensed Exporter Claim For Refund Page 4
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4Schedule B -
Exports of Petroleum Products Intended for Direct Delivery Outside Tennessee - Unlicensed Exporter Claim for Refund (Attach to PET 380)
Exporter Name:
Destination State:
Product Type:
Month of (MM-YY):
Tennessee Department of Revenue
Product Type (Circle One)
M O D E
65 GASOLINE
142 KEROSENE
J TRUCK
122 BLENDING COMPONENTS (TRANSMIX)
160 UNDYED DIESEL
R RAIL
123 ALCOHOL
226 DIESEL (HIGH SULFUR DYED)
B BARGE
124 GASOHOL
227 DIESEL (LOW SULFUR DYED)
PL PIPELINE
125 AVIATION GASOLINE
____ OTHER (SEE ITA PRODUCT CODE LIST)
B A BOOK ADJUSTMENT
130 JET FUEL
ST STOCK TRANSFER
POINT OF
TERMINAL
PURCHASED
SHIPPING
CARRIER
CUSTOMER
SHIP
SALES
EXPORT
CODE #
FROM
PAPER #
CARRIER NAME
FEIN
MODE
ORIGIN
DESTINATION
SOLD TO:
FEIN #
DATE
DOCUMENT #
GALLONS
Total Gallons
See schedule instructions on back
RV-F1402101
INTERNET (4-03)
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Parent category: Financial