Form 575 - Terminal Operator Report - Missouri Department Of Revenue
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Document Locator Number
Missouri Department of Revenue
Form
Terminal Operator Report
575
Name of Terminal
Month and Year
Amended
Additional
Terminal Code
r
r
Report
Report
___ ___ /___ ___ ___ ___
Location of Terminal
City
State
Zip
Company Name
License Number
Street Address
PO Box
City
State
Zip
Federal Employer Identification Number
Telephone Number
Fax Number
(___ ___ ___)___ ___ ___–___ ___ ___ ___
(___ ___ ___)___ ___ ___–___ ___ ___ ___
Aviation
Undyed Diesel
Liquefied Natural
Dyed Diesel
Blending
Transaction For The Month
Gasoline
Alcohol
Gasohol
Jet Fuel
Gasoline
& Kerosene
Gas (LNG)
& 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
Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct.
Signature
Title
Printed Name
Date (MM/DD/YYYY)
___ ___ /___ ___ /___ ___ ___ ___
Form 575 (Revised 01-2016)
Mail to: Taxation Division
Phone: (573) 751-2611
P.O. Box 300
TTY: (800) 735-2966
Jefferson City, MO 65105-0300
Fax: (573) 522-1720
Visit
for additional information.
E-mail:
excise@dor.mo.gov
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Parent category: Financial