Fuel Allowance Form - Michigan

Form 3978, Page 3

Preparer's Signat ure Printed Name

Telephone Number Preparer FEINPreparer's Address

I certify under penalty of perjury that I have examined this return and to the best of my knowledge and belief, it is true and complete. Suppliers of Gasoline/Ethanol

Blends/Aviation Fuel: I certify to the best of my knowledge and belief that any and all suppliers, w holesalers or retailers of gasoline or aviation fuel to w hom gasoline or aviation

fuel, as defined by statute, was sold by this supplier during the period covered by this report, have been paid or credited as follows:

(A) To Suppliers/Wholesalers - 1.5% of the tax charged as allowed by statute to licensed suppliers of gasoline or aviation fuel.

(B) To Retailers - 1/3 of the 1.5% allowed by statute to licensed suppliers of gasoline or aviation fuel.

(C) No credits or payments have been extended during this report period as no sales of gasoline or aviation fuel have been

made to any supplier/wholesaler or retailer.

I authorize Treasury to discuss my return and attachments with my preparer. Do not discuss with my preparer.

Authorized Signature Printed Name Telephone Number

CERTIFICATIONS

Title Date

Suppliers and Permissive Suppliers are mandated to file electronically. This form is for information purposes only.

Mail Remittance to:

Michigan Department of Treasury