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Document Locator Number
Form
Missouri Department of Revenue
591
Supplier Delinquent Tax Collection
Page ____ of ____
Supplier’s Name
Month and Year
License Number
Federal Employer Identification Number
__ __ /__ __ __ __
Eligible Purchaser’s Name
License Number
Federal Employer Identification Number
Complete a separate schedule for each product type.
r
r
r
r
r
065 - Gasoline
124 - Gasohol
142 - Kerosene
228 - Dyed Diesel Fuel
290 - Bio-Diesel - Dyed B100
r
r
r
r
r
123 - Alcohol
125 - Aviation Gasoline
072 - Dyed Kerosene
284 - Bio-Diesel - Undyed B100
225 - Liquefied Natural Gas
r
r
r
r
r
241 - Ethanol
130 - Jet Fuel
160 - Diesel Fuel
285 - Soy Oil
122 - Blending Components (Identify) ___________
Invoice Date
Invoiced
Total
Document Number
Penalty
Tax Rate
Tax Amount
Interest
Collected
(MM/DD/YYYY)
Gallons
__ __ /__ __ /__ __ __ __
$
$
$
$
00
00
00
00
__ __ /__ __ /__ __ __ __
$
$
$
$
00
00
00
00
__ __ /__ __ /__ __ __ __
$
$
$
$
00
00
00
00
__ __ /__ __ /__ __ __ __
$
$
$
$
00
00
00
00
__ __ /__ __ /__ __ __ __
$
$
$
$
00
00
00
00
Total:
$
$
$
$
00
00
00
00
Invoice Date
Invoiced
Total
Document Number
Penalty
Fee Rate
Fee Amount
Interest
Collected
(MM/DD/YYYY)
Gallons
__ __ /__ __ /__ __ __ __
$
$
$
$
00
00
00
00
__ __ /__ __ /__ __ __ __
$
$
$
$
00
00
00
00
__ __ /__ __ /__ __ __ __
$
$
$
$
00
00
00
00
__ __ /__ __ /__ __ __ __
$
$
$
$
00
00
00
00
__ __ /__ __ /__ __ __ __
$
$
$
$
00
00
00
00
Total:
$
$
$
$
00
00
00
00
Invoice Date
Invoiced
Total
Document Number
Fee Rate
Fee Amount
Penalty
Interest
Collected
(MM/DD/YYYY)
Gallons
__ __ /__ __ /__ __ __ __
$
$
$
$
00
00
00
00
__ __ /__ __ /__ __ __ __
$
$
$
$
00
00
00
00
__ __ /__ __ /__ __ __ __
$
$
$
$
00
00
00
00
__ __ /__ __ /__ __ __ __
$
$
$
$
00
00
00
00
__ __ /__ __ /__ __ __ __
$
$
$
$
00
00
00
00
Total:
$
$
$
$
00
00
00
00
Invoice Date
Invoiced
Total
Document Number
Bond Rate
Bond Amount
Penalty
Interest
Collected
(MM/DD/YYYY)
Gallons
__ __ /__ __ /__ __ __ __
$
$
00
00
__ __ /__ __ /__ __ __ __
$
$
00
00
__ __ /__ __ /__ __ __ __
$
$
00
00
__ __ /__ __ /__ __ __ __
$
$
00
00
__ __ /__ __ /__ __ __ __
$
$
00
00
Total:
$
$
00
00
Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct.
Signature
Title
Printed Name
Date (MM/DD/YYYY)
__ __ /__ __ /__ __ __ __
Form 591 (Revised 01-2016)
Mail to: Taxation Division
Phone: (573) 751-2611
P.O. Box 300
Fax: (573) 522-1720
Visit
Jefferson City, MO 65105-0300
TTY: (800) 735-2966
for additional information.
E-mail:
excise@dor.mo.gov