Form 4760 - Supplier Notification Of Uncollectible Tax
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MISSOURI DEPARTMENT OF REVENUE
DLN
FORM
TAXATION DIVISION
4760
P.O. BOX 300, JEFFERSON CITY, MO 65105-0300
(573) 751-2611
TDD (800) 735-2966
(REV. 02-2011)
SUPPLIER NOTIFICATION OF UNCOLLECTIBLE TAX
COMPLETE A SEPARATE SCHEDULE FOR EACH DEFAULTING ELIGIBLE PURCHASER
SEE INSTRUCTIONS ON REVERSE SIDE
SUPPLIER’S NAME
LICENSE NUMBER
FEIN
TELEPHONE NUMBER
(_ _ _) _ _ _ - _ _ _ _
__ __ __ __ __ __ __ __ __
ELIGIBLE PURCHASER INFORMATION
ELIGIBLE PURCHASER’S NAME
LICENSE NUMBER
FEIN
__ __ __ __ __ __ __ __ __
TRANSACTION INFORMATION
Document Number
Selling Date
Fuel Code
Invoiced Gallons
0
TOTAL
SUPPLIER’S AUTHORIZED REPRESENTATIVE (PLEASE PRINT)
SIGNATURE
DATE
__ __ / __ __ / __ __ __ __
This publication is available upon request in alternative accessible format(s).
MO 860-2839 (02-2011)
MISSOURI DEPARTMENT OF REVENUE
DLN
FORM
TAXATION DIVISION
4760
P.O. BOX 300, JEFFERSON CITY, MO 65105-0300
(573) 751-2611
TDD (800) 735-2966
(REV. 02-2011)
SUPPLIER NOTIFICATION OF UNCOLLECTIBLE TAX
COMPLETE A SEPARATE SCHEDULE FOR EACH DEFAULTING ELIGIBLE PURCHASER
SEE INSTRUCTIONS ON REVERSE SIDE
SUPPLIER’S NAME
LICENSE NUMBER
FEIN
TELEPHONE NUMBER
(_ _ _) _ _ _ - _ _ _ _
__ __ __ __ __ __ __ __ __
ELIGIBLE PURCHASER INFORMATION
ELIGIBLE PURCHASER’S NAME
LICENSE NUMBER
FEIN
__ __ __ __ __ __ __ __ __
TRANSACTION INFORMATION
Document Number
Selling Date
Fuel Code
Invoiced Gallons
0
TOTAL
SUPPLIER’S AUTHORIZED REPRESENTATIVE (PLEASE PRINT)
SIGNATURE
DATE
__ __ / __ __ / __ __ __ __
This publication is available upon request in alternative accessible format(s).
MO 860-2839 (02-2011)
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