DLN
MISSOURI DEPARTMENT OF REVENUE
FORM
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TAXATION DIVISION
8A
P.O. BOX 300, JEFFERSON CITY, MO 65105-0300
(573) 751-2611
TDD (800) 735-2966
(REV. 03-2011)
AFFIDAVIT FOR BAD DEBT LOSS
SEE INSTRUCTIONS ON REVERSE SIDE
SUPPLIER’S NAME
LICENSE NUMBER
FEIN
MONTH, YEAR
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ADDRESS
P.O. BOX
CITY
STATE
ZIP
TELEPHONE NUMBER
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(__ __ __) __ __ __ - __ __ __ __
Claim information — Attach copies of all documents identified below.
Supplier credit is limited to amount due from purchaser and any amount accruing for a period not to exceed ten (10) days or the date of notification to the director,
whichever is earlier following date of failure to make payment. Round to whole dollars.
Eligible Purchaser
Document
Tax/Fee Rate
Eligible Purchaser’s Name
Selling Date
Gallons Invoiced
Product Type
Total Amount Claimed
License Number
Number
Charged
$
00
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$
00
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$
00
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$
00
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$
00
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$
00
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$
00
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$
00
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$
00
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$
00
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$
00
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0
TOTAL AMOUNT CLAIMED FOR CREDIT
$
00
I declare and affirm under penalties of perjury that this report has been examined by me, and to the best of my knowledge and belief is in all things true and correct. "I also declare under penalties of perjury that I employ no illegal or unau-
thorized aliens as defined under federal law and that I am not eligible for any tax exemption, credit or abatement if I employ such aliens."
PRINT NAME
SIGNATURE
TITLE
DATE
__ __ / __ __ / __ __ __ __
DOR USE ONLY
ORIGINAL NOTIFICATION POST-MARK
DOR AUTHORIZED REPRESENTATIVE
AMOUNT APPROVED FOR CREDIT
$
00
This publication is available upon request in alternative accessible format(s).
DOR-571 (03-2011)
MO 860-1109 (03-2011)