Form 4758 - Schedule Of Supplier State Diversion Corrections Page 2
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2This schedule(s) provides detail in support of the amount(s) shown as diversion corrections on Supplier or Permissive Supplier’s Monthly
Tax Report,
(Form
572).
Each diversion of product should be listed on separate lines. Complete a separate schedule for each product type.
If you have questions or need assistance in completing this form, please call (573) 751-2611 or e-mail excise@dor.mo.gov. You may
also access the Department’s web site at
to obtain this form.
Identifying Information
Company Name, License Number and FEIN — Enter the name and numbers for the supplier shown on the supplier report.
Column Instructions
Name of Carrier — Enter the name and FEIN of the company that transports the product.
Mode of Transport — Enter the mode of transport from the terminal. Use one of the following:
J = Truck
R = Rail
B = Barge
PL = Pipeline
BA = Book Adjustment
ST = Stationary Transfer
Original Destination or Revised Destination — Enter the name of the destination state as it originally appears on the shipping
document. Enter the name of the destination state to where the product was diverted.
Terminal Code — Use the IRS Terminal Control Code.
Purchaser’s Name and FEIN — Enter the name and FEIN of the company the product was sold to.
Date Shipped — Enter the month, day, and year the product was shipped.
Document Number — Enter the identifying number from the document issued at the terminal where product is removed from the rack.
In case of pipeline or barge movements, enter the pipeline or barge ticket number. In case of bulk plant removals, it is the withdrawal
invoice.
Net Gallons — Enter the net amount of gallons diverted.
Gross Gallons — Enter the gross amount of gallons diverted.
Invoiced Gallons — Enter the number of gallons billed (should equal either net or gross gallons). Carry this figure forward to the
reverse side of Supplier or Permissive Supplier’s Monthly Tax Report, (Form 572) Line 14W.
Diversion Number — Enter the diversion number issued by the State of Missouri, or its registered agent.
Form 4758 (Revised 01-2016)
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