Form 4755 - Notification Of Loss Of Motor Fuel
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MISSOURI DEPARTMENT OF REVENUE
DLN
FORM
TAXATION DIVISION
4755
P.O. BOX 300, JEFFERSON CITY, MO 65105-0300
(573) 751-2611
TDD (800) 735-2966
(REV. 02-2011)
NOTIFICATION OF LOSS OF MOTOR FUEL
SEE INSTRUCTIONS ON REVERSE SIDE
COMPANY NAME
LICENSE NUMBER
FEIN
TELEPHONE NUMBER
__ __ __ __ __ __ __ __ __
(__ __ __) __ __ __ - __ __ __ __
ADDRESS
P.O. BOX
CITY
STATE
ZIP
___ ___ ___ ___ ___
PRODUCT CODE
065 — Gasoline
124 — Gasohol
142 — Kerosene
228 — Dyed Diesel Fuel
290 — Bio-Diesel – Dyed B100
123 — Alcohol
125 — Aviation Gasoline
072 — Dyed Kerosene
284 — Bio-Diesel – Undyed B100
122 — Blending Components
241 — Ethanol
130 — Jet Fuel
160 — Diesel Fuel
285 — Soy Oil
(Identify)
LOSS INFORMATION
Date of Loss
Location of Loss
Product Code
Gallons Loss
__ __ / __ __ / __ __ __ __
__ __ / __ __ / __ __ __ __
__ __ / __ __ / __ __ __ __
__ __ / __ __ / __ __ __ __
__ __ / __ __ / __ __ __ __
__ __ / __ __ / __ __ __ __
NAME OF COMPANY REPRESENTATIVE (PLEASE PRINT)
SIGNATURE
DATE
__ __ / __ __ / __ __ __ __
MO 860-2834 (02-2011)
This publication is available upon request in alternative accessible format(s).
MISSOURI DEPARTMENT OF REVENUE
DLN
FORM
TAXATION DIVISION
4755
P.O. BOX 300, JEFFERSON CITY, MO 65105-0300
(573) 751-2611
TDD (800) 735-2966
(REV. 02-2011)
NOTIFICATION OF LOSS OF MOTOR FUEL
SEE INSTRUCTIONS ON REVERSE SIDE
COMPANY NAME
LICENSE NUMBER
FEIN
TELEPHONE NUMBER
__ __ __ __ __ __ __ __ __
(__ __ __) __ __ __ - __ __ __ __
ADDRESS
P.O. BOX
CITY
STATE
ZIP
___ ___ ___ ___ ___
PRODUCT CODE
065 — Gasoline
124 — Gasohol
142 — Kerosene
228 — Dyed Diesel Fuel
290 — Bio-Diesel – Dyed B100
123 — Alcohol
125 — Aviation Gasoline
072 — Dyed Kerosene
284 — Bio-Diesel – Undyed B100
122 — Blending Components
241 — Ethanol
130 — Jet Fuel
160 — Diesel Fuel
285 — Soy Oil
(Identify)
LOSS INFORMATION
Date of Loss
Location of Loss
Product Code
Gallons Loss
__ __ / __ __ / __ __ __ __
__ __ / __ __ / __ __ __ __
__ __ / __ __ / __ __ __ __
__ __ / __ __ / __ __ __ __
__ __ / __ __ / __ __ __ __
__ __ / __ __ / __ __ __ __
NAME OF COMPANY REPRESENTATIVE (PLEASE PRINT)
SIGNATURE
DATE
__ __ / __ __ / __ __ __ __
MO 860-2834 (02-2011)
This publication is available upon request in alternative accessible format(s).
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