Form 4760 - Supplier Notification Of Uncollectible Tax
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Missouri Department of Revenue
Form
4760
Supplier Notification of Uncollectible Tax
DLN
Complete a separate schedule for each defaulting eligible purchaser.
Name and Address
Federal Employer Identification Number (FEIN)
Phone Number
License Number
(
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Name and Address
Federal Employer Identification Number (FEIN)
Phone Number
License Number
(
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Selling Date
Document Number
Fuel Code
Invoiced Gallons
(MM/DD/YYYY)
___ ___ / ___ ___ / ___ ___ ___ ___
___ ___ / ___ ___ / ___ ___ ___ ___
___ ___ / ___ ___ / ___ ___ ___ ___
___ ___ / ___ ___ / ___ ___ ___ ___
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Total
0
___ ___ / ___ ___ / ___ ___ ___ ___
Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct.
Supplier’s Authorized Representative (Printed Name)
Signature
Date
__ __ / __ __ / __ __ __ __
Instructions
This form is to be completed when notifying the Director of Revenue of failure to collect tax from an eligible purchaser.
After completing the Supplier and Purchaser information, enter the requested information identifying the transactions on which tax was not remitted by
the eligible purchaser. Be sure to sign and date the form before remitting it.
Notification of uncollectible tax must be submitted within ten (10) business days following the earliest date on which the supplier was entitled to collect
the tax from the eligible purchaser. Failure to provide notification within the specified period will result in credit being disallowed.
The credit is to be claimed by completing an Affidavit For Bad Debt Loss (Form 8A) and returning it with the first return following the expiration of the
ten-day period.
Credit is limited to the amount of tax and fees due from the purchaser, including any accruals within the ten (10) day notification period.
Fuel Codes
065 — Gasoline
142 — Kerosene
284 — Bio-Diesel – Undyed B100
123 — Alcohol
130 — Jet Fuel
285 — Soy Oil
241 — Ethanol
072 — Dyed Kerosene
290 — Bio-Diesel – Dyed B100
124 — Gasohol
160 — Diesel Fuel
122 — Blending Components
125 — Aviation Gasoline
228 — Dyed Diesel Fuel
(Identify) ______________________
Form 4760 (Revised 06-2013)
Mail to:
Taxation Division
Phone: (573) 751-2611
Visit dor.mo.gov/business/fuel/
P.O. Box 300
Fax: (573) 522-1720
for additional information.
Jefferson City, MO 65105-0300
E-mail: excise@dor.mo.gov
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