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MISSOURI DEPARTMENT OF REVENUE
TAXATION DIVISION
4782
P.O. BOX 300, JEFFERSON CITY, MISSOURI 65105-0300
(573) 751-2611
TDD 1-800-735-2966
(REV. 02-2011)
TRANSPORTER REPORT
COMPANY NAME
MONTH/YEAR
CHECK HERE IF AN AMENDED REPORT
CHECK HERE IF AN ADDITIONAL REPORT
___ ___ / ___ ___ ___ ___
STREET ADDRESS
P.O. BOX
LICENSE NUMBER
FEIN
___ ___ ___ ___ ___ ___ ___ ___ ___
CITY
STATE
ZIP
TELEPHONE NUMBER
MITS NUMBER
___ ___ ___ ___ ___
(__ __ __) __ __ __ - __ __ __ __
___ ___ ___ ___ ___ ___ ___ ___
MUST BE FILED EVERY REPORTING PERIOD
GROSS
NET
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) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
0
0
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 DIVISION, 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 (02-2011)