Free Form 720-CS (Rev. January 2004) - Federal

Form

720-CS
Carrier

Carrier Summary Report
For the month ending , 20 .

OMB No. 1545-1733

(Rev. January 2004)
Department of the Treasury Internal Revenue Service

Corrected

Void

Part I
Company name

Employer Identification Number (EIN)

Address (number, street, room or suite number)

Form 637 Registration Number

City, state, and ZIP code (Foreign addresses, include province and postal code as appropriate. Do not abbreviate country name.)

Contact person

Daytime telephone number

FAX number

Email address

(

)

(

)

Part II

Transactions for the Month

Net Gallons (attach additional schedule(s) if needed)
Enter the transactions for the period on Schedules A and B, then complete lines 1 and 2 for each product code (PC). See page 6 of the instructions for the product codes. (a) PC: 1 Total carrier receipts. Enter the total net gallons from Schedule(s) A, column (f), by product code. If you have receipts from more than one terminal for a product code, you must add the amounts from each terminal's Schedule A and enter the combined total by product code here. Total carrier deliveries. Enter the total net gallons from Schedule(s) B, column (f), by product code. If you have deliveries to more than one terminal for a product code, you must add the amounts from each terminal's Schedule B and enter the combined total by product code here. PC: (b) PC: (c) PC: (d)

2

Under penalties of perjury, I declare that I have examined this return and accompanying schedules, and, to the best of my knowledge and belief, they are true, correct, and complete.

Signature Type or print your name below signature.

Title, if applicable

Date

For Privacy Act and Paperwork Reduction Act Notice, see page 5 of the instructions.

Cat. No. 73073H

Form

720-CS

(Rev. 1-2004)

Form 720-CS (Rev. 1-2004) Carrier name as shown on Form 720-CS EIN Form 637 Registration Number

Corrected

Void

Page

2

For the month ending (enter MM/DD/YYYY)

Schedule A

Carrier Receipts From a Terminal
TCN of terminal

Terminal name. Complete a separate Schedule A for each terminal.

1 Product code (PC). Enter the product code from page 6 of the
instructions. A separate schedule is required for each PC.

1

Page of For more than one Schedule A, for each different PC, number each sheet. For example, 1 of 4, 2 of 4, etc.

2 Enter in the columns below the information requested for the PC on line 1 above. (a) Consignor EIN (b) Consignor name (c) Mode of transportation (d) Document date (e) Document number (f) Net gallons

3 Total. Add all amounts in column (f) for each different PC. If there is more than one page for a PC, add the amounts from each page and enter the
result on the last page of Schedule A for that PC. Do not enter page subtotals. Also, include the amount from column (f) on Form 720-CS, line 1, in the column for the applicable PC
Form

3 720-CS
(Rev. 1-2004)

Form 720-CS (Rev. 1-2004) Carrier name as shown on Form 720-CS EIN Form 637 Registration Number

Corrected

Void

Page

3

For the month ending (enter MM/DD/YYYY)

Schedule B

Carrier Deliveries to a Terminal
TCN of terminal

Terminal name. Complete a separate Schedule B for each terminal.

1 Product code (PC). Enter the product code from page 6 of the
instructions. A separate schedule is required for each PC

1

Page of For more than one Schedule B, for each different PC, number each sheet. For example, 1 of 4, 2 of 4, etc.

2 Enter in the columns below the information requested for the PC on line 1 above. (a) Consignor EIN (b) Consignor name (c) Mode of transportation (d) Document date (e) Document number (f) Net gallons

3 Total. Add all amounts in column (f) for each different PC. If there is more than one page for a PC, add the amounts from each page and enter the
result on the last page of Schedule B for that PC. Do not enter page subtotals. Also, include the amount from column (f) on Form 720-CS, line 2, in the column for the applicable PC
Form

3 720-CS
(Rev. 1-2004)