Form 4012 - Schedule Of Exports

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Michigan Department of Treasury
4012 (Rev. 8-06)
Schedule of Exports
Product Code (see instructions on page 2)
This form is issued under authority of P.A. 403 of 2000, as amended. Filing is mandatory.
Company Name
Account Number (FEIN or TR)
License Number
Report Period (mm/yyyy)
Indicate destination State/Province/Country (A separate schedule must be filed for each state/province/country.)
7A - Gallons exported, destination state tax paid.
7B - Gallons exported, Michigan tax paid.
Report Whole Gallons Only
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)
Point of
Terminal
Sold To (Purchaser)
Date
Document
Gallons
Carrier Name
Carrier FEIN
Mode
Code
Shipped
Number
Net
Gross
Billed
Origin
Dest.
Name
FEIN
TOTALS

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Parent category: Financial
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