Form EIA-878 (Schedule EIA-878 (Schedule Motor Gasoline Price Survey (Schedule A)

U.S. DEPARTMENT OF ENERGY U.S. ENERGY INFORMATION ADMINISTRATION Washington, DC 20585

OMB Number: 1905-0174 Expiration Date: XX/XX/XXXX Burden: 6.5 minutes

EIA-878: MOTOR GASOLINE PRICE SURVEY

Schedule A

This report is mandatory under the Federal Energy Administration Act of 1974 (Public Law 93‑275). Failure to comply may result in criminal fines, civil penalties and other sanctions as provided by law. Title 18 USC 1001 makes it a criminal offense for any person knowingly and willingly to make to any agency or Department of the United States any false, fictitious, or fraudulent statements as to any matter within its jurisdiction. See Instructions for further details on the sanctions and the provisions concerning the confidentiality of information submitted on this form.

Prices for:

Month Day Year

PART 1. IDENTIFICATION DATA
Company Name (only if different than label)
Station Name			8. Name of Contact Person
Station’s Physical Address			9. Mailing/Contact’s Address
Station City	Station State		10. Contact’s City		11.Contact’s State	12. Contact’s ZIP Code
Station ZIP Code	Station Telephone Number		13. Contact’s Email Address		14. Contact’s Telephone Number
The information you provide on Form EIA-878 will be used for statistical purposes only. Your responses will be kept confidential and will not be disclosed in identifiable form. Per the Federal Cybersecurity Enhancement Act of 2015, Federal information systems are protected from malicious activities through cybersecurity screening of transmitted data. By law, every EIA employee, as well as every agent, is subject to a jail term, a fine, or both if he or she makes public ANY identifiable information you reported.
PART 2. PRICE DATA
Enter your station’s total retail price of self-service, cash only, gasoline for each grade, including all taxes.
Grade		Ethanol Content (%)		Price (in dollars per gallon)
Regular (85, 86, 87 octane)				$
Midgrade (88, 89, 90 octane)				$
Premium (91+ octane)				$
Other (specify octane rating)____________				$
Other (specify octane rating)____________				$
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