Form 572 - Supplier/permissive Supplier'S Monthly Tax Report Page 2
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1
2WORKSHEET OF MOTOR FUEL GALLONS
Column A
Column B
Column C
Column D
Column E
Column F
Column G
Column H
From
Clear
Form 2994
100%
Dyed
EXPORT SALES
Aviation
Blending
Diesel
Schedule
Gasoline
Ethyl
Gasohol
Diesel &
Jet Fuel
Gasoline
Components
& Clear
Alcohol
Kerosene
Reset This Section Only
Kerosene
7
1W. Gallons exported by suppliers ..........................
2W. Gallons removed by licensed distributors
5H
for export (Destination state tax paid) ..............
0
3W. Total export sales (Lines 1W and 2W) ...............................
0
0
0
0
0
0
0
Column A
Column B
Column C
Column D
Column E
Column F
Column G
Column H
From
Clear
Form 573
100%
Dyed
ADJUSTMENTS
Aviation
Blending
Diesel
Schedule
Gasoline
Ethyl
Gasohol
Diesel &
Jet Fuel
Gasoline
Components
& Clear
Alcohol
Kerosene
Reset This Section Only
Kerosene
1
4A. Gallons received tax and/or fees paid ..............
4B. Sales to U.S. government (credit card and
Form 2994
Form 4776, Ultimate Vendor Certificate) ..........
10D
4W. Total adjustments (Lines 4A and 4B; enter on
Line 2, front of report) ........................................................
0
0
0
0
0
Column A
Column B
Column C
Column D
Column E
Column F
Column G
Column H
From
TAX EXEMPT SALES
Clear
100%
Dyed
Form 2994
Aviation
Blending
(FEES APPLY)
Diesel
Gasoline
Ethyl
Gasohol
Diesel &
Jet Fuel
Schedule
Gasoline
Components
& Clear
Alcohol
Kerosene
Reset This Section Only
Kerosene
5W. Gallons delivered to U.S. government
8
tax exempt .......................................................
6W. Clear kerosene sold for non-highway
6
use and jet fuel ................................................
7W. Gallons of dyed diesel and dyed kerosene
5A + 5B
removed for nonhighway use ..........................
0
0
0
8W. Total tax exempt gallons (Lines 5W through 7W) ............
Column A
Column B
Column C
Column D
Column E
Column F
Column G
Column H
From
Clear
100%
Dyed
TAX AND FEE EXEMPT SALES
Form 2994
Aviation
Blending
Diesel
Gasoline
Ethyl
Gasohol
Diesel &
Jet Fuel
Schedule
Gasoline
Components
& Clear
Reset This Section Only
Alcohol
Kerosene
Kerosene
6
9W. Gallons of other tax-exempt fuel ..................
Column A
Column B
Column C
Column D
Column E
Column F
Column G
Column H
From
Clear
TAXABLE SALES
100%
Dyed
Form 2994
Aviation
Blending
Diesel
Gasoline
Ethyl
Gasohol
Diesel &
Jet Fuel
Schedule
Gasoline
Components
& Clear
Reset This Section Only
Alcohol
Kerosene
Kerosene
5A + 5B
10W. Taxable sales ...................................................
11W. Enter gallons of the blending components
5A + 5B
under the fuel type which it was added ............
12W. Dyed diesel sold for taxable purposes from
5F
in-state terminals (Missouri tax collected) ........
13W. Dyed diesel sold for taxable purposes
5G
for import ..........................................................
14W. State diversion corrections (Plus
Form 4758
or minus) ..........................................................
Sched. 11
15W. Total taxable gallons (Lines 10W through 14W)
(Enter on Line 1, front of report) .........................................
0
0
0
0
0
(09-2011)
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