Form 4754 - Schedule Of Terminal Operator Receipts April 2015
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Document Locator Number
Missouri Department of Revenue
Form
4754
Schedule of Terminal Operator Receipts
Page _______ of _______
Terminal Operator
Terminal Code
Schedule Type
Federal Employer I.D. Number
Month and Year
__ __ /__ __ __ __
Type of Schedule (Select One)
Select One
r
r
r
r
r
r
TR - Gallons Received
065 - Gasoline
124 - Gasohol
142 - Kerosene
228 - Dyed Diesel Fuel
290 - Bio-Diesel – Dyed B100
r
r
r
r
r
123 - Alcohol
125 - Aviation Gasoline
072 - Dyed Kerosene
284 - Bio-Diesel – Undyed B100
225 - Liquefied Natural Gas (LNG)
r
2X - Gallons Received per
r
r
r
r
r
241 - Ethanol
130 - Jet Fuel
160 - Diesel Fuel
285 - Soy Oil
122 - Blending Components (Identify) ______________
Exchange Agreement
Carrier Federal Employer
Supplier’s Federal Employer
Date Received
Document
Net
Gross
Name of Carrier
Mode
Supplier
Identification Number
Identification Number
(MM/DD/YYYY)
Number
Gallons
Gallons
__ __ /__ __ /__ __ __ __
__ __ /__ __ /__ __ __ __
__ __ /__ __ /__ __ __ __
__ __ /__ __ /__ __ __ __
__ __ /__ __ /__ __ __ __
__ __ /__ __ /__ __ __ __
__ __ /__ __ /__ __ __ __
__ __ /__ __ /__ __ __ __
__ __ /__ __ /__ __ __ __
__ __ /__ __ /__ __ __ __
__ __ /__ __ /__ __ __ __
__ __ /__ __ /__ __ __ __
__ __ /__ __ /__ __ __ __
__ __ /__ __ /__ __ __ __
__ __ /__ __ /__ __ __ __
0
0
Page Total
Mail to: Taxation Division
Phone: (573) 751-2611
P.O. Box 300
Fax: (573) 522-1720
Visit
Schedule Total
Jefferson City, MO 65105-0300
TTY: (800) 735-2966
for additional information.
Form 4754 (Revised 04-2015)
E-mail:
excise@dor.mo.gov
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