Form  720-CS                                                                                                                       OMB No. 1545-1733
                                               Carrier Summary Report
(Rev. September 2010)
Department of the Treasury 
Internal Revenue Service          For the month ending                             , 20 .                                               Corrected Void
Part I      Carrier
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 instructions).
                                                                 (a)               (b)                                         (c)         (d)
                                                        PC:                    PC:        PC:                                           PC:
1     Total receipts.Enter the total net gallons from 
      Schedule(s) A, column (g), by PC. If you have 
      receipts from more than one facility for a PC, 
      add the amounts from each facility's Schedule 
      A and enter the combined total by PC.

2     Total deliveries. Enter the total net gallons  
      from Schedule(s) B, column (g), by PC. If you 
      have deliveries to more than one facility for a 
      PC, you must add the amounts from each 
      facility’s Schedule B and enter the combined 
      total by PC.

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

Signature ▶                                             Title, if applicable ▶                                                     Date ▶

Type or print your name below signature.
For Privacy Act and Paperwork Reduction Act Notice, see the separate instructions.      Cat. No. 73073H                            Form 720-CS (Rev. 9-2010)

Form 720-CS (Rev. 9-2010)                                                                                                                              Corrected          Void        Page 2
Carrier name as shown on Form 720-CS                                       EIN                              Form 637 registration number           For the month ending (enter MM/DD/YYYY)

Schedule A     Carrier Receipts 
Facility name. Complete a separate Schedule A for each facility.                                                                                   Facility control number

                                                                                                      Page                                     of
1 Product Code (PC). Enter the PC (see instructions). A separate schedule is                          For more than one Schedule A, for each different PC, number each sheet. For 
  required for each PC      . .      . . . . . .                 . . . . . .   . . . .   ▶            example, 1 of 4, 2 of 4, etc.

2 Enter in the columns below the information requested for the PC on line 1 above.
                                                                                                        (d) 
         (a)                                   (b)                                 (c)                                                    (e)                  (f)             (g) 
                                                                                                Vessel official number 
       Consignor                           Consignor                               Mode                                                 Document         Document              Net 
                                                                                                  (required when mode               
         EIN                                 name                                  code                                                   date             number              gallons
                                                                                              code is B, S, IB, IS, EB, or ES)

3 Total. Add all amounts in column (g) and enter the total. 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. Enter the amount from column (g) on   Form  720-CS, Part II, line 1, in the column for the 
  applicable PC . .       . . .      . . . . . .                 . . . . . .   . . . .  . . . . . . . . .   . . .      .      . .   . . . . .  . . .   .   . .  .    ▶    3
                                                                                                                                                                     Form 720-CS (Rev. 9-2010)

Form 720-CS (Rev. 9-2010)                                                                                                                             Corrected            Void        Page 3
Carrier name as shown on Form 720-CS                                       EIN                              Form 637 registration number            For the month ending (enter MM/DD/YYYY)

Schedule B      Carrier Deliveries
Facility name. Complete a separate Schedule B for each facility.                                                                                    Facility control number

                                                                                                      Page                                    of
1 Product Code (PC).        Enter the PC (see instructions). A separate schedule is                   For more than one Schedule B, for each different PC, number each sheet. For 
  required for each PC      . .      . . . .  . .                . . . . . .   . . . .   ▶            example, 1 of 4, 2 of 4, etc.
2 Enter in the columns below the information requested for the PC on line 1 above.
                                                                                                        (d) 
           (a)                                  (b)                                (c)                                                   (e)                   (f)              (g) 
                                                                                                Vessel official number 
      Consignor                            Consignor                               Mode                                               Document          Document                Net 
                                                                                                  (required when mode  
           EIN                                name                                 code                                                  date              number               gallons
                                                                                              code is B, S, IB, IS, EB, or ES)

3 Total.Add amounts in column (g) and enter the total. 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. Enter the amount from column (g)    on Form 720-CS, Part II, line 2, in the column for   
  the applicable PC       . . .      . . . .  . .                . . . . . .   . . . .  . . . . . . . . .   .  . .     .      . . . . .  . .  . .   . . .  .    .    ▶     3
                                                                                                                                                                     Form 720-CS (Rev. 9-2010)