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S completed form for your records. Name of distributor Part FEIN Month/year 1 Receipts from sources located outside this state Date Mode of Carrier s name Seller s name Origin Destination received delivery and FEIN and FEIN terminal control terminal control number or number or (city, state) (city, state) A Gallons purchased on which the tax has been passed through to you Column A total gallons (enter here and include in the amount o.

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