Form 8a - Affidavit For Bad Debt Loss - Missouri Department Of Revenue - 2006

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MISSOURI DEPARTMENT OF REVENUE

DLN

FORM

TAXATION BUREAU

P.O. BOX 300, JEFFERSON CITY, MO 65105-0300

(573) 751-2611

TDD (800) 735-2966

(REV. 11-2006)

AFFIDAVIT FOR BAD DEBT LOSS

SEE INSTRUCTIONS ON REVERSE SIDE

SUPPLIER’S NAME

LICENSE NUMBER

FEIN

MONTH, YEAR

ADDRESS

P.O. BOX

CITY

STATE

ZIP

TELEPHONE NUMBER

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

TOTAL AMOUNT CLAIMED FOR CREDIT

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.

PRINT NAME

SIGNATURE

TITLE

DATE

DOR USE ONLY

ORIGINAL NOTIFICATION POST-MARK

DOR AUTHORIZED REPRESENTATIVE

AMOUNT APPROVED FOR CREDIT

This publication is available upon request in alternative accessible format(s).

DOR-571 (11-2006)

MO 860-1109 (11-2006)