Form 4757 Draft - Distributor'S Monthly Tax Report - 2011 Page 4

A convenience

fee will be charged to your account for processing. If you pay by

check, you authorize the Department to process the check electroni-

cally. Any returned check may be presented again electronically.

Mail the report and schedules to: Missouri Department of Revenue,

Taxation Division, P.O. Box 300, Jefferson City, Missouri 65105-

0300.

If you have questions or need assistance in completing this

form, please call (573) 751-2611 or you can e-mail excise@dor.

mo.gov. You may also access the Department’s web site at

to obtain this

form.

Please ensure that you sign, indicate your title, and date the report.

MOTOR FUEL TAX, AVIATION GASOLINE TAX, INSPECTION

FEE, TRANSPORT LOAD FEE AND POOL BOND ARE FIVE

SEPARATE ACCOUNTS. DO NOT USE A CREDIT ON ONE

ACCOUNT TO PAY FOR ANOTHER ACCOUNT. (EXAMPLE:

MOTOR FUEL TAX CREDIT CANNOT BE USED TO PAY

AVIATION GASOLINE TAX.)

(09-2011)

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Parent category: Financial