Form 572 - Supplier Permissive Supplier'S Monthly Tax Report
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MISSOURI DEPARTMENT OF REVENUE
DLN
FORM
TAXATION BUREAU
572
P.O. BOX 300, JEFFERSON CITY, MO 65105-0300
(573) 751-2611
TDD (800) 735-2966
(REV. 11-2006)
SUPPLIER/PERMISSIVE SUPPLIER’S MONTHLY TAX REPORT
SEE INSTRUCTIONS ON PAGE 3 — ROUND TO WHOLE GALLONS AND DOLLARS
COMPANY NAME
MONTH/YEAR
CHECK HERE IF
CHECK HERE IF
AMENDED REPORT
ADDITIONAL REPORT
STREET ADDRESS
P.O. BOX
LICENSE NUMBER
FEIN
CITY
STATE
ZIP
TELEPHONE NUMBER
COMPLETE REVERSE SIDE FIRST — ROUND TO WHOLE GALLONS
COLUMN E
COLUMN F
COLUMN B
COLUMN C
COLUMN D
COLUMN A
100% Ethyl
Clear Diesel &
Dyed Diesel &
Gasoline
CALCULATION OF MOTOR FUEL TAX DUE
Gasohol
Aviation Gasoline
Alcohol
Clear Kerosene
Dyed Kerosene
1. Gross taxable gallons (Line 15W on worksheet) . . . . . . . . . . . . . . . . . . . .
2. Tax adjustments (Line 4W on worksheet) . . . . . . . . . . . . . . . . . . . . . . . . .
3. Taxable gallons (Line 1 minus Line 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3%
3%
3%
3%
2%
2%
4. Allowance (3% of Line 3 Columns A, B, C, & D) (2% of Line 3
Columns E and F) (If report is filed late or tax is not paid by the due
date, enter zero) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5. Net taxable gallons (Line 3 minus Line 4) . . . . . . . . . . . . . . . . . . . . . . . . .
TAX CALCULATION — ROUND TO WHOLE DOLLARS
× $.17
× $.17
× $.17
× $.09
× $.17
× $.17
Tax Rates
6. Tax due (Line 5 times tax rate indicated above) . . . . . . . . . . . . . . . . . . . .
$
$
$
$
$
$
00
00
00
00
00
00
7. Supplier credit (Line 6 x $.001) (If return is filed late or tax
is not paid by the due date, enter zero) . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
$
$
$
$
$
00
00
00
00
00
00
8. Tax due (Line 6 minus Line 7) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
$
$
$
$
$
00
00
00
00
00
00
9. Credit/debit authorization (Attach copy of letter) . . . . . . . . . . . . . . . . . . . .
$
$
$
$
$
$
00
00
00
00
00
00
10. Total tax due (Total of Lines 8 and 9) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
$
$
$
$
$
00
00
00
00
00
00
INSPECTION FEE
— ROUND TO WHOLE GALLONS AND DOLLARS
TOTAL TAXES, FEES, AND POOL BOND DUE
11. Gallons subject to inspection fee (Lines 8W
plus 15W minus Line 4A on worksheet) . . . . . . . . . . . .
21. Total fuel taxes due (Line 10, Columns A,
$
B, C, E, and F) . . . . . . . . . . . . . . . . . . . . . . . . . .
00
12. Inspection fee due at $0.025 per 50 gallons . . . . . . . . .
$
00
22. Total aviation gasoline tax due (Line 10,
$
Column D) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
00
13. Credit/debit authorization (Attach copy of letter) . . . . . .
$
00
23. Total inspection fee due (Line 14) . . . . . . . . . . .
$
00
14. Total inspection fee due (Total of Line 12 and Line 13) .
$
00
TRANSPORT LOAD FEE
— ROUND TO WHOLE GALLONS & DOLLARS
24. Total transport load fee due (Line 20) . . . . . . . .
$
00
15. Gallons subject to transport load fee
25. Total tax and fees due (Lines 21,
(Line 11 above) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
22, 23, and 24) . . . . . . . . . . . . . . . . . . . . . . . . . .
$
00
16. Gallons sold to railroad corporations and airline
26. Penalty (5% per month up to 25%
companies (Total from Schedule 10) . . . . . . . . . . . . . . .
of Line 25) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
00
17. Total gallons subject to transport load fee
(Line 15 minus Line 16) . . . . . . . . . . . . . . . . . . . . . . . . .
27. Interest (8% per annum of Line 25) . . . . . . . . . .
$
00
18. Transport load fee (Line 17 divided by
28. Total taxes, fees, penalty, and interest due
8,000 gallons times $40.00) . . . . . . . . . . . . . . . . . . . . . .
$
(Lines 25, 26, and 27) . . . . . . . . . . . . . . . . . . . . .
00
$
00
19. Credit/debit authorization
29. Pool bond collections (Total from
(Attach copy of letter) . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
00
Form 4759, Schedule 5T) . . . . . . . . . . . . . . . . .
$
00
20. Total transport load fee due
30. Total amount remitted (Line 28 plus
(Total of Lines 18 and 19) . . . . . . . . . . . . . . . . . . . . . . .
Line 29) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
00
$
00
If you pay by check, you authorize the Department of Revenue to process the check electronically. Any check returned unpaid may be presented again electronically.
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 and payment to: Missouri Department of Revenue, Taxation Bureau, Excise Tax, P.O. Box 300, Jefferson City, MO 65105-0300.
MO 860-1416 (11-2006)
This publication is available upon request in alternative accessible format(s).
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