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MISSOURI DEPARTMENT OF REVENUE
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FORM
TAXATION BUREAU
P.O. BOX 300
575
JEFFERSON CITY, MO 65105-0300
(573) 751-2611
TDD 1-800-735-2966
(REV. 11-2006)
TERMINAL OPERATOR REPORT
TERMINAL
NAME OF TERMINAL
MONTH/YEAR
CHECK HERE
CHECK HERE
IF AMENDED
IF ADDITIONAL
REPORT
REPORT
LOCATION OF TERMINAL
TERMINAL CODE
CITY
STATE
ZIP
OPERATOR
COMPANY NAME
LICENSE NUMBER
FEIN
STREET ADDRESS
PO BOX
CITY
STATE
ZIP
TELEPHONE NUMBER
FAX NUMBER
TRANSACTION
COLUMN D
COLUMN E
COLUMN F
COLUMN H
COLUMN A
COLUMN B
COLUMN C
COLUMN G
TRANSACTION FOR THE MONTH
AVIATION
UNDYED DIESEL &
DYED DIESEL &
BLENDING
GASOLINE
ALCOHOL
GASOHOL
JET FUEL
GASOLINE
KEROSENE
KEROSENE
COMPONENTS
1. Beginning Inventory (Previous month’s ending
inventory)
2. Total Receipts (From Terminal Receipts
Schedule TR plus 2X)
3. Total Gallons Available (Line 1 plus Line 2)
4. Total Disbursements (From Terminal
Disbursement Schedule TD plus 6X)
5. Gallons Available (Line 3 minus Line 4)
6. Stock Gains & Losses (+ or -)
7. Actual Ending Inventory
I do hereby certify under penalty of perjury that the foregoing and attached reports are a true and correct statement to the best of my knowledge and is a complete and full presentation
of all transactions from the best information available.
PRINT NAME
SIGNATURE
TITLE
DATE
Mail report and payment to: Missouri Department of Revenue, Taxation Bureau, Excise Tax, P.O. Box 300, Jefferson City, MO 65105-0300.
This publication is available upon request in alternative accessible format(s).
MO 860-1112 (11-2006)