Form 4757 - Distributor'S Monthly Tax Report - Missouri Department Of Revenue - 2017

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Document Locator Number
Reset Form
Form
Missouri Department of Revenue
4757
Distributor’s Monthly Tax Report
Print Form
Company Name
Month and Year
Amended Report
Additional Report
r
r
__ __ /__ __ __ __
Street Address
P.O. Box
License Number
Federal Identification Number
City
State
ZIP Code
Telephone Number
Missouri Tax Identification Number
(__ __ __) __ __ __-__ __ __ __
Round to Whole Gallons
Dyed Diesel &
100% Ethyl
Aviation
Clear Diesel &
Compressed Natural
Liquefied Natural
Gasoline
Gasohol
Kerosene
Alcohol
Gasoline
Clear Kerosene
Gas (CNG)
Gas (LNG)
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 Lines1, 2, 3,
and 4) ...........................................................
6. Gallons of fuel exported, Missouri tax paid
(From worksheet, Line 14) .............................
3%
3%
3%
3%
3%
2%
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) ...
Round to Whole Dollars
x $.17
x $.17
x $.17
x $.05
x $.09
x $.17
x $.05
x $.17
00
00
00
00
00
00
00
00
10. Tax Due - (Line 9 times appropriate tax rates) ....
11. Credit authorization (Attach copy of letter) ....
00
00
00
00
00
00
00
00
12. Total motor fuel tax (Line 10 minus Line 11) .
00
00
00
00
00
00
00
00
Round to Whole Dollars
Round to Whole Gallons and Dollars
25. Total fuel tax due (Line 12, All columns except aviation
13. Gallons subject to inspection fee (From worksheet, total of Lines
00
5, 6, 17, and 17A minus Line 18) ....................................................
gasoline) ......................................................................
00
14. Gallons of fuel exported fees paid (From worksheet, Line 14) ........
26. Total aviation gasoline tax due (Line 12) .....................
00
15. Gallons subject to inspection fee (Line 13 minus Line 14) ..............
27. Total inspection fee due (Line 18) ..............................
00
16. Inspection fee due (Line 15 times $0.035 per 50 gallons)
28. Total transport load fee due (Line 24) .........................
00
00
(.0007 per gallon) ..............................................................................
29. Total taxes and fees due (Lines 25, 26, 27, and 28) ....
00
17. Credit authorization (Attach copy of letter) .......................................
00
30. Penalty (5% per month up to 25% of Line 29) .............
18. Total inspection fee due (Line 16 minus Line 17) ............................
00
31. Interest (See Line 31 of instructions -- Compute using
00
total on Line 29) ...........................................................
Round to Whole Dollars
32. Total taxes, fees, penalty and interest due (Lines 29,
00
19. Gallons subject to transport load fee (Line 15 above) .....................
30, and 31) ..................................................................
20. Deduct gallons sold to railroad corporations and airline companies
33. Pool bond amount due (From
Form
4759,
00
(total from attached Schedule 10K, 10R, or 10Y) ............................
Schedule 5T) ...............................................................
21. Total gallons subject to transport load fee (Line 19 minus Line 20) ......
34. Total amount remitted (Line 32 plus Line 33) ..............
00
22. Transport load fee (Line 21 divided by 8,000 gals. x $20.00)
If you have a credit on Line 34 select one of the boxes:
00
(.0025 per gallon) ..............................................................................
r
Credit to next report
23. Credit authorization (Attach copy of letter) .......................................
00
r
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.
Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct.
Print Name
Signature
Title
Date (MM/DD/YYYY)
__ __ /__ __ /__ __ __ __
Form 4757 (Revised 04-2017)
Mail to: Taxation Division
Phone: (573) 751-2611
P.O. Box 300
Fax: (573) 522-1720
Jefferson City, MO 65105-0300
TTY: (800) 735-2966
Visit
E-mail:
excise@dor.mo.gov
for additional information.

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