Form 572 - Supplier Permissive Supplier'S Monthly Tax Report Page 4
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428. Total taxes, fees, penalty, and interest due (Total of Lines 25,
You may also access the department’s web site at
26, and 27).
to obtain this form.
MOTOR FUEL TAX, AVIATION GASOLINE FUEL TAX, INSPEC-
POOL BOND PAYMENT
TION FEE, TRANSPORT LOAD FEE, AND POOL BOND ARE
29. Pool Bond amount collected from distributors (Enter total figure
FIVE SEPARATE ACCOUNTS. DO NOT USE A CREDIT ON ONE
from Form 4759, Schedule 5T.)
ACCOUNT TO PAY FOR ANOTHER ACCOUNT.
SUPPLIER UNCOLLECTIBLE ACCOUNTS
30. Total amount remitted. (Total of Lines 28 plus (+) 29)
Make check or money order payable to Missouri Department of
Supplier uncollectible accounts. (Enter total from Form 8A, Bad Debt
Revenue. Mail the report and schedules to: Missouri Department of
Affidavit). To receive credit, the supplier must notify the Department
Revenue, Taxation Bureau, Excise Tax, P.O. Box 300, Jefferson
within 10 days following the earliest date the supplier was entitled to
City, Missouri 65105-0300.
collect the tax from the eligible purchaser. Enter the uncollectible
fuel tax under the appropriate column on Line 9. List uncollectible
Please print your name and title, sign, and date the report.
inspection fee on Line 13 and uncollectible transport load fee on
Line 19.
If you have questions or need assistance in completing this form,
please call (573) 751-2611 or you can e-mail excise@dor.mo.gov.
This publication is available upon request in alternative accessible format(s).
MO 860-1416 (11-2006)
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