Form 573 - Schedule Of Supplier Tax-Paid Receipts - 2016
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Document Locator Number
Missouri Department of Revenue
Form
573
Schedule of Supplier Tax-Paid Receipts
Page _______ of _______
Supplier’s Name
License Number
Schedule Type
Federal Employer I.D. Number
Month and Year
__ __ /__ __ __ __
1
Select One (Complete a separate schedule for each product type)
r
r
r
r
r
065 - Gasoline
124 - Gasohol
142 - Clear Kerosene
284 - Bio-Diesel - Undyed B100
285 - Soy Oil
r
r
r
r
r
123 - Alcohol
125 - Aviation Gasoline
072 - Dyed Kerosene
228 - Dyed Diesel Fuel
225 - Liquefied Natural Gas
r
r
r
r
r
122 - Blending Components (Identify) _____________
241 - Ethanol
130 - Jet Fuel
160 - Clear Diesel Fuel
290 - Bio-Diesel - Dyed B100
Point of
Carrier’s
Seller’s
Date
Document
Net
Gross
Invoiced
Name of Carrier
Mode
Seller’s Name
FEIN
FEIN
Shipped
Number
Gallons
Gallons
Gallons
Origin
Dest.
Page Total
Mail to: Taxation Division
Phone: (573) 751-2611
Visit
P.O. Box 300
Fax: (573) 522-1720
Schedule Total
Jefferson City, MO 65105-0300
TTY: (800) 735-2966
for additional information.
E-mail:
excise@dor.mo.gov
Form 573 (Revised 01-2016)
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