Form Omf-11 Draft - Terminal Operator Report
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4Division use only - DLN Stamp
Division use only Date Stamp
Month
Year
Due Date:
Mail with Report to:
New Jersey Division of
On or before the last day of
Taxation, PO Box 189,
the month following the
Trenton, NJ, 08695-0189
report month.
Pursuant to NJSA 54:39-11et seq
10/1/10
TERMINAL OPERATOR REPORT
OMF-11
FID#
TERMINAL NUMBER
NAME OF OPERATOR
NAME OF TERMINAL
ADDRESS - NUMBER & STREET
LOCATION OF TERMINAL
CITY
STATE
ZIP CODE
CITY
STATE
ZIP CODE
GASOLINE
DIESEL/KEROSENE
LPG
1. Fuel in Inventory Beginning of Year
2. Total Fuel Received During the Year
3.
Total Fuel Available (line 1 plus line 2)
4. Total Fuel Disbursements During the Year
5. Ending Inventory (line 3 minus line 4)
6.
Total Fuel Accounted for (line 4 plus line 5)
7. Gain or Loss (line 3 minus line 6)
8. Actual Ending Inventory
I declare under penalties provided by the law that all the information contained in this return and in all schedules and statements in support of it is true and accurate in every particular.
Title
Date
Signature of authorized Officer of Taxpayer
Federal Identification Number
Date
Signature of Individual or Firm Preparing Return
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