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Missouri Tax Identification Number
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A. Direct Material ........................................................................................................................................... A
$
B. Direct Labor .............................................................................................................................................. B
C. Overhead Expenses
1. Plant Equipment—Depreciation ..................................................................... C1
2. Plant Equipment—Insurance ......................................................................... C2
PART D — COST OF PRODUCTION
3. Plant Equipment—Taxes ............................................................................... C3
4. Plant Building Rent or Depreciation ............................................................... C4
5. Compensation Insurance or Similar Cost ...................................................... C5
6. Indirect Labor ................................................................................................. C6
7. Utilities ........................................................................................................... C7
8. List Other Expenses ________________________________________ ..... C8
Total Overhead Expenses (Total C1–C8)................................................................................................. C
D. Total Cost of Production (Total A, B and C) ............................................................................................. D
$
0
1. Total cost of electrical energy used in operation (Part C, Column 2) ............................................................
1
2. Total cost of producing product or exempt operation (Part D, Line D) ..........................................................
2
3. Total cost of electrical energy used directly in exempt operation (Part C, Column 3) ..................................
3
4. Total production costs less electrical energy used in production or exempt operation (Line 2 minus Line 3) .
4
5. Ten percent of Line 4 (Line 4 times .10) .......................................................................................................
5
6. Percentage of electrical energy used in production to total cost of production exclusive of electrical
energy so used (Line 3 divided by Line 4) .....................................................................................................
6
Description of Qualifying Process and Products Produced
Final Return: If this is your final return, enter the close date below and select the reason for closing your account. The Sales Tax law
requires any person selling or discontinuing business to make a final sales tax return within fifteen (15) days of the sale or closing.
Date Business Closed: ___________________________________________
Out of Business
Sold Business
Leased Business
The calculation in Part E, Summary determines if you qualify for this exemption for the next calendar year. If you do not qualify, it is your
responsibility to notify your utility provider, withdraw your exemption, and remit the appropriate tax to the state.
Under penalties of perjury, I declare that I have direct control, supervision or responsibility for completing this return. I attest that I have
no taxable utility purchases to report for locations left blank.
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.
Sign and Date Return: This must be signed and dated by the taxpayer or by the taxpayer’s authorized agent.
Signature of Taxpayer or Agent
Print Name
Title
Date Signed (MM/DD/YYYY)
Tax Period (MMDDYYYY) Thru (MMDDYYYY)
Thru
__ __ / __ __ / __ __ __ __
__ __ / __ __ / __ __ __ __
__ __ / __ __ / __ __ __ __
Form 53-E10 (Revised 12-2013)