Form Mvf-3 - Terminal Operator'S Monthly Gasoline Activity Schedule Page 2
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4Department of Revenue Services
State of Connecticut
Part 2 - Receipts (Continued)
Terminal Operator’s Monthly Gasoline Activity Schedule
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.:
Type of Gasoline by Gross Gallons
Receipts
Name of
Date of Delivery
Method of Delivery
Unleaded Regular
Unleaded Mid-Grade
Unleaded Premium
Total Gross Gallons
Transporter or Vessel
Totals (Transfer to Page 1, Part 2)
Page 2 of 4
Form MVF-3 (Rev. 10/10)
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Parent category: Financial