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FORM
MISSOURI DEPARTMENT OF REVENUE
TAXATION BUREAU
4782
P.O. BOX 300, JEFFERSON CITY, MISSOURI 65105-0300
(573) 751-2611
TDD 1-800-735-2966
(REV. 11-2006)
TRANSPORTER REPORT
COMPANY NAME
MONTH/YEAR
CHECK HERE IF AMENDED REPORT
STREET ADDRESS
P.O. BOX
LICENSE NUMBER
FEIN
CITY
STATE
ZIP
TELEPHONE NUMBER
MITS NUMBER
MUST BE FILED EVERY REPORTING PERIOD
NET
GROSS
1. Total gallons of petroleum product loaded at a Missouri terminal or bulk plant delivered to
1
another state. (Attach Schedule 1A) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2. Total gallons of petroleum product loaded at an out-of-state terminal or bulk plant and delivered
2
in Missouri (Attach Schedule 2A) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3. Total gallons of petroleum product loaded at a Missouri terminal or bulk plant and delivered in
3
Missouri (Attach Schedule 3A) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4
4. Total gallons of petroleum transported (Total of Lines 1 through 3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
I DO HEREBY CERTIFY UNDER THE PENALTY OF PERJURY THAT THE FOREGOING AND ATTACHED REPORTS ARE A TRUE AND CORRECT STATEMENT TO THE BEST OF MY KNOWLEDGE AND A COMPLETE AND FULL
PRESENTATION OF ALL TRANSACTIONS FROM THE BEST INFORMATION AVAILABLE.
PRINT NAME
SIGNATURE
TITLE
DATE
MAIL REPORT TO: MISSOURI DEPARTMENT OF REVENUE, TAXATION BUREAU, EXCISE TAX, P.O. BOX 300, JEFFERSON CITY, MO 65105-0300.
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.
This form is available upon request in alternative accessible format(s).
MO 860-2848 (11-2006)