Form Mf-360 - Schedule 11 - Schedule Of State Diversion Corrections

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MF-360 Schedule 11
State Form 55345
(7-09)
Schedule of State Diversion Corrections
Distributor
License Number
FEIN
Month / Year
You may photocopy this blank schedule for future filings. Attach additional sheets if necessary.
Please see the product code matrix on the Web site at
Carrier Information
(4)
Purchaser Information
Original
Revised
(1)
(2)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)
(13)
(3)
Dest.
Dest.
Diversion
Carrier
Carrier
Terminal
Purchaser
Purchaser
Date
Document
Net
Gross
Billed
Mode
Name
FEIN
State
State
Code
Name
FEIN
Shipped
Number
Gallons
Gallons
Gallons
Number
Total

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