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MISSOURI DEPARTMENT OF REVENUE
DLN
TAXATION DIVISION
FORM
P.O. BOX 300, JEFFERSON CITY MO 65105-0300
4759
(573) 751-2611
TDD (800) 735-2966
SCHEDULE OF POOL BOND
(REV. 02-2011)
PAGE
CONTRIBUTIONS—5T
OF
SEE INSTRUCTIONS ON REVERSE SIDE
SUPPLIER’S OR DISTRIBUTOR’S NAME
LICENSE NUMBER
MONTH
YEAR
___ ___ ___ ___
PRODUCT TYPE — Complete a separate schedule for each product type
CIRCLE ONE
065 — Gasoline
125 — Aviation Gasoline
160 — Clear Diesel Fuel
290 — Bio-Diesel – Dyed B100
123 — Alcohol
130 — Jet Fuel
228 — Dyed Diesel Fuel
122 — Blending Components
241 — Ethanol
142 — Clear Kerosene
284 — Bio-Diesel – Undyed B100
(Identify)
124 — Gasohol
072 — Dyed Kerosene
285 — Soy Oil
DISTRIBUTOR INFORMATION
Selling
Distributor’s
Document
Gallons
Distributor’s Name
Number
Date
FEIN
Invoiced
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0
ROUND TO WHOLE GALLONS AND DOLLARS
PAGE TOTAL
PAGE TOTAL — POOL BOND MONEY COLLECTED — MOTOR FUEL GALLONS TIMES $.0024
$
00
POOL BOND MONEY COLLECTED — AVIATION FUEL GALLONS TIMES $.0013
$
00
SCHEDULE TOTAL — ALL POOL BOND MONEY COLLECTED
$
00
CREDIT AUTHORIZATION (ATTACH COPY OF LETTER)
$
00
TOTAL DUE (ENTER ON LINE 29 OF FORM 572 OR LINE 33 OF FORM 4757)
$
00
I declare under penalties of perjury that I employ no illegal or unauthorized aliens as defined under federal law and that I am not eligible for any tax
exemption, credit or abatement if I employ such aliens.
MO 860-2838 (02-2011)
This publication is available upon request in alternative accessible format(s).