MISSOURI DEPARTMENT OF REVENUE
DLN
FORM
TAXATION DIVISION
P.O. BOX 300, JEFFERSON CITY, MO 65105-0300
4757
(573) 751-2611 TDD (800) 735-2966
DISTRIBUTOR’S MONTHLY TAX REPORT
(REV. 09-2011)
SEE INSTRUCTIONS ON REVERSE SIDE
COMPANY NAME
MONTH/YEAR
CHECK HERE IF:
AMENDED
ADDITIONAL
__ __ / __ __ __ __
REPORT
REPORT
STREET ADDRESS
P.O. BOX
LICENSE NUMBER
FEDERAL ID NUMBER
__ __ __ __ __ __ __ __ __
CITY
STATE
ZIP
TELEPHONE NUMBER
MO TAX ID NUMBER
___ ___ ___ ___ ___
__ __ __ __ __ __ __ __
(__ __ __) __ __ __ - __ __ __ __
GALLONS SUBJECT TO TAX — ROUND TO WHOLE GALLONS
COLUMN E
COLUMN F
COLUMN B
COLUMN A
COLUMN C
COLUMN G
COLUMN D
100% Ethyl
Clear Diesel &
Dyed Diesel &
Aviation Gasoline
Gasoline
Gasohol
Jet Fuel
Alcohol
Clear Kerosene
Kerosene
1. Gallons of blend stock received tax unpaid (From
worksheet, Line 6) .................................................
2. Gallons of fuel received in Missouri tax unpaid
(From worksheet, Line 5) ........................................
3. Gallons of tax exempt product blended for
taxable use (From worksheet, Line 17) .................
4. Gallons of dyed fuel sold for taxable
purposes (From worksheet, Line 11) .....................
5. Gallons subject to tax (Total of Lines
1, 2, 3, and 4) ..........................................................
6. Gallons of fuel exported, Missouri tax paid
(From worksheet, Line 14) .........................................
3%
3%
3%
3%
2%
7. Less allowance (Line 6 times appropriate %) .........
8. Net gallons of fuel exported, Missouri tax paid
(Line 6 minus Line 7) ....................................................
9. Net gallons subject to tax (Line 5 minus Line 8) .....
TAX CALCULATION — ROUND TO WHOLE DOLLARS
x $.17
x $.17
x $.17
x $.09
x $.17
x $.17
Tax Rates
10. Tax Due — (Line 9 times appropriate tax rates) .....
00
00
00
00
00
00
$
$
$
$
$
11. Credit authorization (Attach copy of letter) ............
00
00
00
00
00
00
$
$
$
$
$
12. Total motor fuel tax (Line 10 minus Line 11) .............
$
$
$
$
$
00
00
00
00
00
00
INSPECTION FEE
TOTAL TAXES, FEES, AND POOL BOND DUE — ROUND TO
— ROUND TO WHOLE GALLONS AND DOLLARS
13. Gallons subject to inspection fee (From worksheet, total
WHOLE DOLLARS
of Lines 5, 6, 17, and 17A) .....................................................
25. Total fuel tax due (Line 12, Columns A, B, C, E,
14. Gallons of fuel exported fees paid (From worksheet,
$
and F) ..................................................................................
00
Line 14) .................................................................................
15. Gallons subject to inspection fee (Line 13 minus Line 14) ...
26. Total aviation gasoline tax due (Line 12, Column D) ...........
$
00
27. Total inspection fee due (Line 18) .......................................
16. Inspection fee due (Line 15 times $0.025 per
$
00
00
50 gallons) (.0005 per gallon) ...............................................
17. Credit authorization (Attach copy of letter) ..........................
00
28. Total transport load fee due (Line 24) ..................................
$
$
00
18. Total inspection fee due (Line 16 minus Line 17) ................
29. Total taxes and fees due (Lines 25, 26,
00
$
27, and 28) ...........................................................................
$
00
TRANSPORT LOAD FEE — ROUND TO WHOLE DOLLARS
30. Penalty (5% per month up to 25% of Line 29) .....................
$
00
19. Gallons subject to transport load fee (Line 15 above) .........
31. Interest (See Line 31 of instructions--Compute using total
20. Deduct gallons sold to railroad corporations and airline
on Line 29) ...........................................................................
$
00
companies (total from attached Schedule 10K, 10R, or 10Y)
32. Total taxes, fees, penalty and interest due (Lines 29,
21. Total gallons subject to transport load fee
30, and 31) ............................................................................
$
00
(Line 19 minus Line 20) ...........................................................
33. Pool bond amount due (From Form 4759, Schedule 5T) .....
$
00
22. Transport load fee (Line 21 divided by 8,000 gals. x $20.00)
34. Total amount remitted (Line 32 plus Line 33) ......................
(.0025 per gallon)
....................................................................
$
00
$
00
If you have a credit on Line 34 check one of the boxes:
23. Credit authorization (Attach copy of letter) ..........................
00
$
Credit to next report
Refund
24. Total transport load fee due (Line 22 minus Line 23) ..........
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 trans-
actions 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)