Form 4757 - Distributor'S Monthly Tax Report - Missouri Department Of Revenue - 2017 Page 2
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1
2
3Clear
Liquified
100%
Dyed
Compressed
From
Aviation
Diesel
Jet
Gasoline
Gasohol
Natual
Diesel &
Receipts (Invoiced Gallons)
Ethyl
Natural Gas
Schedule
Gasoline
& Clear
Fuel
Gas (LNG)
Alcohol
(CNG)
Kerosene
Kerosene
1
1. Gallons received in Missouri tax and fees paid .......
1B
2. Gallons received for export, destination state tax
paid ..........................................................................
1C
3. Gallons received tax and fee paid with an import
payment voucher ......................................................
4. Gallons imported from another state, Missouri tax
1E
and fees paid ...........................................................
5. Gallons received tax and fees unpaid (provide
2A
explanation on Schedule 2A) (Example: tank wagon
imports) ....................................................................
5a. Gallons received of tax exempt product
2A
(Example: alcohol, bio-diesel – undyed B100) .......
6. Gallons of blend stock received tax and fees unpaid
(List type of blend stock) _________________
2B
(Enter gallons under the appropriate product
column) ....................................................................
7. Gallons of clear kerosene received fees paid
2G
(For sale through barricaded pumps) .......................
8. Gallons received tax exempt fuel for sale to U.S.
government (Attach copy of
Form
4776) .................
9. Total Receipts ............................................................................................
10. Gallons sold or used by distributor ..........................
5
11. Gallons of dyed fuel sold for taxable purposes .........
10G
12. Gallons of other authorized tax exempt sales
(alcohol, bio-diesel – undyed B100) .......................
7A
13. Gallons exported (Destination state tax paid to
supplier) ..................................................................
7B
14. Gallons exported (Missouri tax and fees paid) .......
10J
15. Gallons of clear kerosene delivered to filling stations
(Barricaded pumps only) .........................................
16. Total Disbursements .................................................................
Tax Exempt Product Removed from Storage for Blending
5W
17. Gallons of tax exempt product blended during
reporting period tax and fees unpaid. ..................
17A. Gallons of tax exempt product blended during
10A
reporting period fees unpaid ................................
10U
18. Gallons of fee exempt product ..................................
Form 4757 (Revised 04-2017)
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