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DLN
FORM
MISSOURI DEPARTMENT OF REVENUE
TAXATION DIVISION
4783
P.O. BOX 300, JEFFERSON CITY, MISSOURI 65105-0300
POSTMARK DATE
(573) 751-2611 TDD (800) 735-2966
(REV. 10-2011)
CONSUMER PAYMENT VOUCHER
SEE INSTRUCTIONS ON REVERSE SIDE
CONSUMER’S NAME
MONTH/YEAR OF USAGE
___ ___ / ___ ___ ___ ___
STREET ADDRESS
FEIN/SOCIAL SECURITY NUMBER
___ ___ ___ ___ ___ ___ ___ ___ ___
PO BOX
CITY
STATE
ZIP
__ __ __ __ __
TELEPHONE NUMBER
E-MAIL ADDRESS
FAX
(___ ___ ___ ) ___ ___ ___ - ___ ___ ___ ___
(__ __ __ ) __ __ __ - __ __ __ __
PURCHASE INFORMATION — ROUND TO WHOLE GALLONS AND DOLLARS
Total
Location of Purchase
Type of Product
Date of
Gallons
Purchase Price
Name of Retailer
(City, State)
Purchased
Purchase
Purchased
Excluding Tax
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
_ _ / _ _ / _ _ _ _
TOTAL
0
TAX CALCULATION — ROUND TO WHOLE GALLONS AND DOLLARS
0
1. Total gallons purchased ...............................................................................................................................................
00
2. Tax due (Line 1 times $ 0.17) ......................................................................................................................................
$
3. Penalty due (Line 2 times 5% per month up to 25%) ..................................................................................................
00
$
00
4. Interest due (Computed using total from Line 3) (See Line 4 of instructions) ..............................................................
$
0
00
5. Total Due ....................................................................................................................................................................
$
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 declare under the penalties of perjury that this return including any accompanying schedules and statements has been examined by me and to the best of my knowledge and
belief is a true, correct, and complete return made in good faith for the taxable period stated, pursuant to existing laws requiring the filing of this return.
PRINT NAME
AUTHORIZED SIGNATURE
DATE
__ __ / __ __ / __ __ __ __
(10-2011)