Fillable Form 4759 - Schedule Of Pool Bond Contributions-5t printable pdf download

Form 4759 - Schedule Of Pool Bond Contributions-5t

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MISSOURI DEPARTMENT OF REVENUE

DLN

TAXATION DIVISION

FORM

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

4759

(573) 751-2611

TDD (800) 735-2966

SCHEDULE OF POOL BOND

(REV. 02-2011)

PAGE

CONTRIBUTIONS—5T

SEE INSTRUCTIONS ON REVERSE SIDE

SUPPLIER’S OR DISTRIBUTOR’S NAME

LICENSE NUMBER

MONTH

YEAR

___ ___ ___ ___

PRODUCT TYPE — Complete a separate schedule for each product type

CIRCLE ONE

065 — Gasoline

125 — Aviation Gasoline

160 — Clear Diesel Fuel

290 — Bio-Diesel – Dyed B100

123 — Alcohol

130 — Jet Fuel

228 — Dyed Diesel Fuel

122 — Blending Components

241 — Ethanol

142 — Clear Kerosene

284 — Bio-Diesel – Undyed B100

(Identify)

124 — Gasohol

072 — Dyed Kerosene

285 — Soy Oil

DISTRIBUTOR INFORMATION

Selling

Distributor’s

Document

Gallons

Distributor’s Name

Number

Date

FEIN

Invoiced

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ROUND TO WHOLE GALLONS AND DOLLARS

PAGE TOTAL

PAGE TOTAL — POOL BOND MONEY COLLECTED — MOTOR FUEL GALLONS TIMES $.0024

POOL BOND MONEY COLLECTED — AVIATION FUEL GALLONS TIMES $.0013

SCHEDULE TOTAL — ALL POOL BOND MONEY COLLECTED

CREDIT AUTHORIZATION (ATTACH COPY OF LETTER)

TOTAL DUE (ENTER ON LINE 29 OF FORM 572 OR LINE 33 OF FORM 4757)

I declare under penalties of perjury that I employ no illegal or unauthorized aliens as defined under federal law and that I am not eligible for any tax

exemption, credit or abatement if I employ such aliens.

MO 860-2838 (02-2011)

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