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

Form

720-TO
Terminal Operator

Terminal Operator Report
For the month ending , 20 .

OMB No. 1545-1734

(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

Contact person

Daytime telephone number

Fax number

Email address

(

)

(

)
Terminal Control Number (TCN)

Part II

Terminal

Name of terminal

Terminal location

Part III

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 through 7 for each product code (PC). See page 6 of the instructions for the product codes.
(a) PC: PC: (b) PC: (c) PC: (d)

1 2

Beginning inventory. Total receipts. Enter the total net gallons from Schedule(s) A, column (f), by product code. Total gallons available. Add lines 1 and 2. Total disbursements. Enter the total net gallons from Schedule(s) B, column (e). If you have disbursements for more than one position holder for a product code, add the amounts from each position holder's Schedule B and enter the combined total by product code here. Subtract line 4 from line 3. Stock gains and losses. Show losses in (parentheses). Actual physical ending inventory at terminal.

3 4

5 6 7

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. 73072W

Form

720-TO

(Rev. 1-2004)

Form 720-TO (Rev. 1-2004) Terminal operator name as shown on Form 720-TO EIN TCN

Corrected

Void

Page

2

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

Schedule A

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

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

2 Enter in the columns below the information requested for the PC on line 1 above. (c) (a) (b) Mode of Carrier Carrier transportation name EIN

(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-TO, line 2, in the column for the applicable PC

3
Form

720-TO

(Rev. 1-2004)

Form 720-TO (Rev. 1-2004) Terminal operator name as shown on Form 720-TO EIN TCN

Corrected

Void

Page

3

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

Schedule B

Terminal Operator Disbursements by Position Holder
PH EIN PH Form 637 Registration Number

Position holder (PH) name. Enter one name per page.

Page

of

For more than one Schedule B, for each different PC, DS, or MT, number each sheet. For example, 1 of 4, 2 of 4, etc. Complete lines 1 through 4 for each product code.

1 Product code (PC). Enter the product code from page 6 of the instructions. A separate schedule is required for each PC 2 Destination state (DS). Enter the destination state for each product code from page 7 of the instructions. A separate schedule is required for
each PC by state. PC 167 destined for Virginia (VA) and Maryland (MD) requires 2 schedules

1 2 3

3 Mode of transportation (MT). Enter the mode of transportation (see page 3 of the instructions) for each product code for each destination state.
PC 167 destined for Virginia by truck and rail and destined for Maryland by truck and rail would require four separate schedules: (1) PC 167, VA, rail; (2) PC 167, VA, truck; (3) PC 167, MD, rail; and (4) PC 167, MD, truck

Example. ABC Terminal is preparing Schedule B for disbursements made by position holder XYZ. XYZ disburses gasoline (PC 065), diesel fuel #2 low sulphur undyed
(PC 167), and jet fuel (PC 130) during the month destined for two states by truck. ABC must prepare six Schedules B to report XYZ's transactions (3 product codes x 2 destination states). A further breakdown by mode of transportation is not needed because only truck was used. 4 Enter in the columns below the information requested for the product code on line 1 above.

(a) Carrier name

(b) Carrier EIN

(c) Document date

(d) Document number

(e) Net gallons

(f) Gross gallons

5 Totals. Add all amounts in columns (e) and (f) for each PC, DS, or MT. If there are two modes of transportation for a product
destined for one state, or if a product is destined for two states, then two Schedules B and totals are required. If there is more than one Schedule B for a PC, DS, or MT, add the amounts from each schedule and enter the result on the last page of Schedule B for each different PC, DS, or MT. Do not enter page subtotals. Also include the amount from column (e) for each PC on Form 720-TO, line 4, in the column for the applicable PC

5e
Form

5f 720-TO
(Rev. 1-2004)