Form 4754 - Schedule Of Terminal Operator Receipts
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1DLN
MISSOURI DEPARTMENT OF REVENUE
FORM
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TAXATION DIVISION
4754
P.O. BOX 300, JEFFERSON CITY, MO 65105-0300
(573) 751-2611
TDD (800) 735-2966
PAGE
(REV. 02-2011)
SCHEDULE OF TERMINAL OPERATOR RECEIPTS
OF
SEE INSTRUCTIONS ON REVERSE SIDE
TERMINAL OPERATOR
TERMINAL CODE
SCHEDULE TYPE
FEIN
MONTH, YEAR
__ __ __ __ __ __ __ __ __
__ __ / __ __ __ __
PRODUCT TYPE (CIRCLE ONE)
TYPE OF SCHEDULE (List one per sheet)
065 — Gasoline
124 — Gasohol
142 — Kerosene
228 — Dyed Diesel Fuel
290 — Bio-Diesel – Dyed B100
TR — Gallons Received
123 — Alcohol
125 — Aviation Gasoline
072 — Dyed Kerosene
284 —Bio-Diesel – Undyed B100
122 — Blending Components
2X — Gallons Received per Exchange Agreement
241 — Ethanol
130 — Jet Fuel
160 — Diesel Fuel
285 — Soy Oil
(Identify)
5
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9
1
2
3
4
SUPPLIER’S
DATE
DOCUMENT
NET
GROSS
NAME OF CARRIER
CARRIER FEIN
MODE
SUPPLIER
FEIN
RECEIVED
NUMBER
GALLONS
GALLONS
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0
PAGE TOTAL
0
SCHEDULE TOTAL
This publication is available upon request in alternative accessible format(s).
MO 860-2833 (02-2011)
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Parent category: Financial