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 No. 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 know ingly and w illingly to make
to any agency or Department of the United States any false, fictitious, or fraudulent statements as to any matter w ithin its j urisdiction. 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
1.

Company Name (only if different than label)

2.

Station Name

8. Name of Contact Person

3.

Station’s Physical Address

9. Mailing/Contact’s Address

4.

Station City

5.

Station State

10. Contact’s City

11.Contact’s
State

6.

Station ZIP Code

7.

Station Telephone Number

13. Contact’s Email Address

14. Contact’s Telephone Number

12. Contact’s ZIP
Code

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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