Form 4757 - Distributor'S Monthly Tax Report Page 2
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4WORKSHEET OF MOTOR FUEL GALLONS
Clear
Dyed
RECEIPTS
From
100% Ethyl
Aviation
Diesel
Gasoline
Gasohol
Diesel &
Jet Fuel
& Clear
Schedule
Alcohol
Gasoline
(INVOICED GALLONS)
Kerosene
Kerosene
1
1. Gallons received in Missouri tax and/or fees paid .........
1B
2. Gallons received for export, destination state tax paid ...
3. Gallons received tax and/or fee paid with an import
1C
payment voucher ...........................................................
4. Gallons imported from another state, Missouri
1E
tax and/or fees paid .......................................................
5. Gallons received tax and/or 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 and/or fees unpaid
(List type of blend stock) ____________ (Enter gallons
2B
under the appropriate product column) ...........................
7. Gallons of clear kerosene received fees paid
(For sale through barricaded pumps) ...............................
2G
8. Gallons received tax exempt fuel for sale to U.S.
government (Attach copy of Form 4776) ........................
9. TOTAL RECEIPTS ........................................................................
Clear
Dyed
From
100% Ethyl
Aviation
Diesel
DISBURSEMENTS
Gasoline
Gasohol
Diesel &
Jet Fuel
& Clear
Schedule
Alcohol
Gasoline
Kerosene
Kerosene
10. Gallons sold or used by distributor
tax and/or fees paid ...................................................
5
11. Gallons of dyed fuel sold for taxable purposes ........
12. Gallons of other authorized tax exempt sales
10G
(alcohol,
) ...........................
bio-diesel – undyed B100
13. Gallons exported (Destination state tax
7A
paid to supplier) ........................................................
7B
14. Gallons exported (Missouri tax and/or fees paid) .....
15. Gallons of clear kerosene delivered to filling
10J
stations (Barricaded pumps only) .............................
16. TOTAL DISBURSEMENTS .......................................................
Clear
Dyed
TAX EXEMPT PRODUCT REMOVED FROM
From
100% Ethyl
Aviation
Diesel
Gasoline
Gasohol
Diesel &
Jet Fuel
& Clear
STORAGE FOR BLENDING
Schedule
Alcohol
Gasoline
Kerosene
Kerosene
17. Gallons of tax exempt product blended during
5W
reporting period tax and fees unpaid. ........................
17A. Gallons of tax exempt product blended during
10A
reporting period fees unpaid. ...................................
(09-2011)
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