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Form 4782 - Transporter Report

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FORM

MISSOURI DEPARTMENT OF REVENUE

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TAXATION DIVISION

4782

P.O. BOX 300, JEFFERSON CITY, MISSOURI 65105-0300

(573) 751-2611

TDD 1-800-735-2966

(REV. 02-2011)

TRANSPORTER REPORT

COMPANY NAME

MONTH/YEAR

CHECK HERE IF AN AMENDED REPORT

CHECK HERE IF AN ADDITIONAL REPORT

___ ___ / ___ ___ ___ ___

STREET ADDRESS

P.O. BOX

LICENSE NUMBER

FEIN

___ ___ ___ ___ ___ ___ ___ ___ ___

CITY

STATE

ZIP

TELEPHONE NUMBER

MITS NUMBER

___ ___ ___ ___ ___

(__ __ __) __ __ __ - __ __ __ __

___ ___ ___ ___ ___ ___ ___ ___

MUST BE FILED EVERY REPORTING PERIOD

GROSS

NET

1. Total gallons of petroleum product loaded at a Missouri terminal or bulk plant delivered to

another state. (Attach Schedule 1A) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2. Total gallons of petroleum product loaded at an out-of-state terminal or bulk plant and delivered

in Missouri (Attach Schedule 2A) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3. Total gallons of petroleum product loaded at a Missouri terminal or bulk plant and delivered in

Missouri (Attach Schedule 3A) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4. Total gallons of petroleum transported (Total of Lines 1 through 3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

I DO HEREBY CERTIFY UNDER THE PENALTY OF PERJURY THAT THE FOREGOING AND ATTACHED REPORTS ARE A TRUE AND CORRECT STATEMENT TO THE BEST OF MY KNOWLEDGE AND A COMPLETE AND FULL

PRESENTATION OF ALL TRANSACTIONS FROM THE BEST INFORMATION AVAILABLE.

PRINT NAME

SIGNATURE

TITLE

DATE

__ __ / __ __ / __ __ __ __

MAIL REPORT TO: MISSOURI DEPARTMENT OF REVENUE, TAXATION DIVISION, EXCISE TAX, P.O. BOX 300, JEFFERSON CITY, MO 65105-0300.

If you have questions or need assistance in completing this form, please call (573) 751-2611 or e-mail excise@dor.mo.gov.

You may also access the Department’s web site at to obtain this form.

This form is available upon request in alternative accessible format(s).

MO 860-2848 (02-2011)