Form Mvf-3 - Terminal Operator'S Monthly Gasoline Activity Schedule

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Department of Revenue Services
Form MVF-3
State of Connecticut
Excise Taxes Unit
Terminal Operator’s Monthly Gasoline Activity Schedule
25 Sigourney St Ste 2
Hartford CT 06106-5032
Due Date: Taxpayers must file schedules for each calendar month with Form O-MF, Motor Vehicle Fuels Tax Return.
(Rev. 10/10)
Name of terminal operator:
Terminal operator CT Tax Registration No.:
Month of:
Address of terminal operator:
Telephone number:
Customer name:
Customer CT Tax Registration No.:
Part 1 - Reconciliation
Type of Gasoline by Gross Gallons
Unleaded Regular
Unleaded Mid-Grade
Unleaded Premium
Total Gross Gallons
1. Opening physical inventory
1.
2. Receipts: Enter Total from Part 2.
2.
3. Subtotal: Add Lines 1 and 2.
3.
4. Disbursements: Enter Total from Part 3.
4.
5. Ending Inventory: Subtract Line 4 from Line 3.
5.
6. Physical inventory taken on last day of month.
6.
7. Loss or Gain: Subtract Line 6 from Line 5.
7.
Part 2 - Receipts
Type of Gasoline by Gross Gallons
Name of
Unleaded Regular
Unleaded Mid-Grade
Unleaded Premium
Date of Delivery
Method of Delivery
Total Gross Gallons
Transporter or Vessel
Page 2, Part 2 totals brought forward
Total receipts - Transfer to Part 1, Line 2
Part 3 - Disbursements
Type of Gasoline by Gross Gallons
Method of Disbursement
Unleaded Regular
Unleaded Mid-Grade
Unleaded Premium
Total Gross Gallons
Disbursements by truck or tank wagon
List other disbursement methods (barge, etc.)
Page 3, Part 3 totals brought forward
Total disbursements - Transfer to Part 1, Line 4
Page 1 of 4

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