Fillable Form 4758 - Schedule Of Supplier State Diversion Corrections (Page 2 of 2) in pdf

Form 4758 - Schedule Of Supplier State Diversion Corrections Page 2

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INSTRUCTIONS FOR SCHEDULE OF SUPPLIER STATE DIVERSION CORRECTIONS

General Instructions

This schedule(s) provides detail in support of the amount(s) shown as diversion corrections on Form 572, Supplier/Permissive Supplier’s Monthly Tax Report.

Each diversion of product should be listed on separate lines. Complete a separate schedule for each product type.

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.

Identifying Information

Company Name, License Number and FEIN:

Enter the name and numbers for the supplier shown on the supplier report.

Column Instructions

Columns 1 and 2:

Name of Carrier — Enter the name and FEIN of the company that transports the product.

Column 3:

Mode of Transport — Enter the mode of transport from the terminal. Use one of the following:

J = Truck

R = Rail

B = Barge

PL = Pipeline

BA = Book Adjustment

ST = Stationary Transfer

Column 4:

Original Destination / Revised Destination — Enter the name of the destination state as it originally appears on the shipping document. Enter the

name of the destination state to where the product was diverted.

Column 5:

Terminal Code — Use the IRS Terminal Control Code.

Columns 6 and 7:

Purchaser’s Name and FEIN — Enter the name and FEIN of the company the product was sold to.

Column 8:

Date Shipped — Enter the date the product was shipped.

Column 9:

Document Number — Enter the identifying number from the document issued at the terminal where product is removed from the rack. In case of

pipeline or barge movements, enter the pipeline or barge ticket number. In case of bulk plant removals, it is the withdrawal invoice.

Column 10:

Net Gallons — Enter the net amount of gallons diverted.

Column 11:

Gross Gallons — Enter the gross amount of gallons diverted.

Column 12:

Invoiced Gallons — Enter the number of gallons billed (should equal either net or gross gallons). Carry this figure forward to the reverse side of Form

572, Supplier/Permissive Supplier’s Monthly Tax Report, Line 14W.

Column 13:

Diversion Number — Enter the diversion number issued by the State of Missouri, or its registered agent.

MO 860-2837 (02-2011)

DOR-4758 (02-2011)