Form 572 - Supplier/permissive Supplier'S Monthly Tax Report

Download a blank fillable Form 572 - Supplier/permissive Supplier'S Monthly Tax Report in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form 572 - Supplier/permissive Supplier'S Monthly Tax Report with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

Reset Form
Print Form
DLN
MISSOURI DEPARTMENT OF REVENUE
FORM
TAXATION DIVISION
572
P.O. BOX 300, JEFFERSON CITY, MO 65105-0300
(573) 751-2611 TDD (800) 735-2966
(REV. 09-2011)
SUPPLIER/PERMISSIVE SUPPLIER’S MONTHLY TAX REPORT
SEE INSTRUCTIONS ON PAGE 3 — ROUND TO WHOLE GALLONS AND DOLLARS
COMPANY NAME
MONTH/YEAR
CHECK HERE IF
CHECK HERE IF
__ __ / __ __ __ __
AMENDED REPORT
ADDITIONAL REPORT
STREET ADDRESS
P.O. BOX
LICENSE NUMBER
FEIN
__ __ __ __ __ __ __ __ __
CITY
STATE
ZIP
TELEPHONE NUMBER
__ __ __ __ __
(__ __ __) __ __ __ - __ __ __ __
CO
COMPLETE REVERSE SIDE FIRST--ROUND TO WHOLE GALLONS
Reset This Section Only
COLUMN E
COLUMN F
COLUMN B
COLUMN D
COLUMN A
COLUMN C
100% Ethyl
Clear Diesel &
Dyed Diesel &
CALCULATION OF MOTOR FUEL TAX DUE
Gasoline
Gasohol
Aviation Gasoline
Alcohol
Clear Kerosene
Dyed Kerosene
1. Gross taxable gallons (Line 15W on worksheet) .........................................
2. Tax adjustments (Line 4W on worksheet) ...................................................
3. Taxable gallons (Line 1 minus Line 2) ........................................................
3%
3%
3%
3%
2%
2%
4. Allowance (3% of Line 3 Columns A, B, C, & D) (2% of Line 3
Columns E and F) (If report is filed late or tax is not paid by the due
date, enter zero) ..........................................................................................
5. Net taxable gallons (Line 3 minus Line 4) ..................................................
TAX CALCULATION — ROUND TO WHOLE DOLLARS
Reset This Section Only
Tax Rates
$.17
$.17
$.17
$.09
$.17
$.17
x
x
x
x
x
x
6. Tax due (Line 5 times tax rate indicated above) ........................................
00
00
00
00
00
00
$
$
$
$
$
$
7. Supplier credit (Line 6 x $.001) (If return is filed late or tax
is not paid by the due date, enter zero) ......................................................
00
00
00
00
00
00
$
$
$
$
$
$
8. Tax due (Line 6 minus Line 7) ....................................................................
$
00
$
00
$
00
$
00
$
00
$
00
9. Credit authorization (Attach copy of letter) .................................................
00
00
00
00
00
00
$
$
$
$
$
$
10. Total tax due (Line 8 minus Line 9) ............................................................
$
00
$
00
$
00
$
00
$
00
$
00
INSPECTION FEE
TOTAL TAXES, FEES, AND POOL BOND DUE
— ROUND TO WHOLE GALLONS AND DOLLARS
Reset This Section Only
11. Gallons subject to inspection fee (Lines 8W
plus 15W minus Line 4A on worksheet) .........................
21. Total fuel taxes due (Line 10, Columns A,
B, C, E, and F) ...................................................
$
00
12. Inspection fee due at $0.025 per 50 gallons ..................
00
$
22. Total aviation gasoline tax due (Line 10,
Column D) ..........................................................
$
00
13. Credit authorization (Attach copy of letter) .....................
00
$
23. Total inspection fee due (Line 14) ......................
$
00
14. Total inspection fee due (Line 12 minus Line 13) ...........
00
$
TRANSPORT LOAD FEE
— ROUND TO WHOLE GALLONS & DOLLARS
24. Total transport load fee due (Line 20) ................
$
00
15. Gallons subject to transport load fee
25. Total tax and fees due (Lines 21,
Reset This Section Only
(Line 11 above) ..............................................................
22, 23, and 24) ...................................................
$
00
16. Gallons sold to railroad corporations and airline
26. Penalty (5% per month up to 25%
companies (Total from Schedule 10) .............................
of Line 25) ..........................................................
$
00
17. Total gallons subject to transport load fee
27. Interest for late payment (Computed using total
(Line 15 minus Line 16) ..................................................
from Line 25)(See Line 27 of instructions) .........
$
00
18. Transport load fee (Line 17 divided by
28. Total taxes, fees, penalty, and interest due
8,000 gallons times $20.00) ...........................................
00
$
00
$
(Lines 25, 26, and 27) .........................................
19. Credit authorization
29. Pool bond collections (Total from
(Attach copy of letter) .....................................................
00
$
00
$
Form 4759, Schedule 5T) ..................................
20. Total transport load fee due
30. Total amount remitted (Line 28 plus
(Line 18 minus Line 19) ..................................................
Line 29) ...............................................................
$
00
00
$
If you pay by check, you authorize the Department of Revenue to process the check electronically. Any check returned unpaid may be presented again electronically.
I do hereby certify under the penalty of perjury that the foregoing and attached reports are a true and correct statement to the best of my knowledge and a complete and
full presentation of all transactions from the best information available. I also declare under penalties of perjury that I employ no illegal or unauthorized aliens as defined
under federal law and that I am not eligible for any tax exemption, credit or abatement if I employ such aliens.
PRINT NAME
SIGNATURE
TITLE
DATE
__ __ /__ __ / __ __ __ __
Mail report and payment to: Missouri Department of Revenue, Taxation Division, Excise Tax, P.O. Box 300, Jefferson City, MO 65105-0300.
(09-2011)

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Financial
Go
Page of 2