Form 4758 - Schedule Of Supplier State Diversion Corrections
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MISSOURI DEPARTMENT OF REVENUE
DLN
FORM
TAXATION DIVISION
4758
P.O. BOX 300, JEFFERSON CITY, MISSOURI 65105-0300
(573) 751-2611
TDD (800) 735-2966
PAGE
(REV. 02-2011)
SCHEDULE OF SUPPLIER STATE DIVERSION CORRECTIONS
OF
SEE INSTRUCTIONS ON REVERSE SIDE
SUPPLIER’S NAME
LICENSE NUMBER
FEIN
SCHEDULE TYPE
MONTH, YEAR
11
__ __ __ __ __ __ __ __ __
__ __ / __ __ __ __
PRODUCT TYPE — Complete a separate schedule for each product type
CIRCLE ONE
065 — Gasoline
142 — Clear Kerosene
228 — Dyed Diesel Fuel
124 — Gasohol
072 — Dyed Kerosene
125 — Aviation Gasoline
160 — Clear Diesel Fuel
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ORIGINAL
NAME OF CARRIER
CARRIER’S
MODE
REVISED
TERMINAL
PURCHASER’S NAME
PURCHASER’S
DATE
DOCUMENT
NET
GROSS
INVOICED
DIVERSION
DEST. STATE
FEIN
DEST. STATE
CODE
FEIN
SHIPPED
NUMBER
GALLONS
GALLONS
GALLONS
NUMBER
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This form is available upon request in alternative accessible format(s).
MO 860-2837 (02-2011)
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Parent category: Financial