Fillable Form 4782 - Transporter Report - 2014 printable pdf download

Form 4782 - Transporter Report - 2014

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Missouri Department of Revenue

Form

4782

Transporter Report

Document Locator Number

Select If An Amended Report

Select If An Additional Report

Company Name

Month and Year

__ __ /__ __ __ __

Street Address

P.O. Box

License Number

Federal Employer Identification Number

City

State

Zip

Telephone Number

Missouri Tax Identification Number

(__ __ __)__ __ __-__ __ __ __

Must Be Filed Every Reporting Period

Gross

Net

1. Total gallons of petroleum product loaded at a Missouri terminal or bulk plant delivered to

another state. (Attach Schedule 1A) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.

2. Total gallons of petroleum product loaded at an out-of-state terminal or bulk plant and delivered

in Missouri (Attach Schedule 2A) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.

3. Total gallons of petroleum product loaded at a Missouri terminal or bulk plant and delivered in

Missouri (Attach Schedule 3A) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.

4. Total gallons of petroleum transported (Total of Lines 1 through 3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.

Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct.

Signature

Print Name

Title

Date (MM/DD/YYYY)

__ __ /__ __ /__ __ __ __

Form 4782 (Revised 05-2014)

Mail to: Taxation Division

Phone: (573) 751-2611

P.O. Box 300

Fax: (573) 522-1720