Form 572 - Supplier Permissive Supplier'S Monthly Tax Report Page 2
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4WORKSHEET OF MOTOR FUEL GALLONS
Column A
Column B
Column C
Column D
Column E
Column F
Column G
Column H
From
Clear
Form 2994
100%
Dyed
EXPORT SALES
Aviation
Blending
Diesel &
Schedule
Gasoline
Ethyl
Gasohol
Diesel &
Jet Fuel
Gasoline
Components
Clear
Alcohol
Kerosene
Kerosene
7
1W. Gallons exported by suppliers . . . . . . . . . . . . .
2W. Gallons removed by licensed distributors
5H
for export (Destination state tax paid) . . . . . . .
3W. Total export sales (Lines 1W and 2W) . . . . . . . . . . . . . . . .
Column A
Column B
Column C
Column D
Column E
Column F
Column G
Column H
From
Clear
Form 573
100%
Dyed
ADJUSTMENTS
Aviation
Blending
Diesel &
Schedule
Gasoline
Ethyl
Gasohol
Diesel &
Jet Fuel
Gasoline
Components
Clear
Alcohol
Kerosene
Kerosene
1
4A. Gallons received tax and/or fees paid . . . . . . . .
4B. Sales to U.S. government (credit card and
Form 2994
Form 4776, Ultimate Vendor Certificate) . . . . .
10D
4W. Total adjustments (Lines 4A and 4B; enter on
Line 2, front of report) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Column A
Column B
Column C
Column D
Column E
Column F
Column G
Column H
From
TAX EXEMPT SALES
Clear
100%
Dyed
Form 2994
Aviation
Blending
(FEES APPLY)
Diesel &
Gasoline
Ethyl
Gasohol
Diesel &
Jet Fuel
Schedule
Gasoline
Components
Clear
Alcohol
Kerosene
Kerosene
5W. Gallons delivered to U.S. government
8
tax exempt . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6W. Clear kerosene sold for non-highway
6
use and jet fuel . . . . . . . . . . . . . . . . . . . . . . . .
7W. Gallons of dyed diesel and dyed kerosene
5A + 5B
removed for nonhighway use . . . . . . . . . . . . .
8W. Total tax exempt gallons (Lines 5W through 7W) . . . . . .
Column A
Column B
Column C
Column D
Column E
Column F
Column G
Column H
From
Clear
100%
Dyed
TAX AND FEE EXEMPT SALES
Form 2994
Aviation
Blending
Diesel &
Gasoline
Ethyl
Gasohol
Diesel &
Jet Fuel
Schedule
Gasoline
Components
Clear
Alcohol
Kerosene
Kerosene
6
9W. Gallons of other tax-exempt fuel . . . . . . . . .
Column A
Column B
Column C
Column D
Column E
Column F
Column G
Column H
From
Clear
100%
Dyed
TAXABLE SALES
Form 2994
Aviation
Blending
Diesel &
Gasoline
Ethyl
Gasohol
Diesel &
Jet Fuel
Schedule
Gasoline
Clear
Components
Alcohol
Kerosene
Kerosene
5A + 5B
10W. Taxable sales . . . . . . . . . . . . . . . . . . . . . . . . . .
11W. Enter gallons of the blending components
5A + 5B
under the fuel type which it was added . . . . . .
12W. Dyed diesel sold for taxable purposes from
5F
in-state terminals (Missouri tax collected) . . . .
13W. Dyed diesel sold for taxable purposes
5G
for import . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
14W. State diversion corrections (Plus
Form 4758
or minus) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Sched. 11
15W. Total taxable gallons (Lines 10W through 14W)
(Enter on Line 1, front of report) . . . . . . . . . . . . . . . . . . . . .
This publication is available upon request in alternative accessible format(s).
MO 860-1416 (11-2006)
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