Form 4707 - Three-Day Import Payment Voucher
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MISSOURI DEPARTMENT OF REVENUE
FORM
TAXATION DIVISION
4707
P.O. BOX 300, JEFFERSON CITY, MO 65105-0300
(573) 751-2611
TDD (800) 735-2966
SEE INSTRUCTIONS ON REVERSE SIDE — MUST
(REV. 09-2011)
THREE-DAY IMPORT PAYMENT VOUCHER
ROUND TO WHOLE GALLONS AND DOLLARS
COMPANY NAME
STREET ADDRESS
LICENSE NUMBER
FEDERAIL ID NUMBER
__ __ __ __ __ __ __ __ __
PO BOX
CITY
STATE
ZIP
TELEPHONE NUMBER
(__ __ __) __ __ __ - __ __ __ __
IMPORT INFORMATION
DATE IMPORT ENTERED MISSOURI
DOCUMENT NUMBER
IMPORT VERIFICATION NUMBER
DATE VERIFICATION NUMBER ASSIGNED
__ __ / __ __ / __ __ __ __
__ __ / __ __ / __ __ __ __
PRODUCT INFORMATION — ROUND TO WHOLE GALLONS AND DOLLARS
Column A
Column B
Taxable Gallons
Non-Taxable Gallons
1
1. Gallons of gasoline ................................................................................................................
2
2. Gallons of alcohol ...................................................................................................................
3
3. Gallons of gasohol .................................................................................................................
4
4. Gallons of clear diesel fuel ......................................................................................................
5
5. Gallons of dyed diesel fuel .....................................................................................................
6
6. Gallons of clear kerosene ......................................................................................................
7
7. Gallons of dyed kerosene ......................................................................................................
8
8. Gallons of aviation gasoline ....................................................................................................
9. Gallons of other non-taxable products (Jet fuel, Bio-Diesel (B100), soy oil, and
9
blending components) ............................................................................................................
10. Total gallons imported taxable and nontaxable (Lines 1 through 9) ..............................
10
MOTOR FUEL TAX CALCULATION — ROUND TO WHOLE GALLONS AND DOLLARS
11
11. Total gallons subject to tax (Column A, Lines 1 through 7) ....................................................
12
$
12. Total tax due (Line 11 times $0.17) ........................................................................................................................
00
13
$
13. Penalty (5% per month up to 25% of total fee due) ...............................................................................................
00
14
$
14. Interest for late payment (see interest information on instructions) ........................................................................
00
15
$
15. Total tax, penalty, and interest due (Total of Lines 12, 13, and 14) .................................................................
00
AVIATION GASOLINE TAX CALCULATION — ROUND TO WHOLE GALLONS AND DOLLARS
16
16. Total gallons subject to tax (Column A, Line 8) .....................................................................
$
17
17. Total of tax due (Line 16 times $0.09) ....................................................................................................................
00
18
$
18. Penalty (5% per month up to 25% of total fee due) ...............................................................................................
00
$
19
19. Interest for late payment (see interest information on instructions) .......................................................................
00
$
20
20. Total aviation tax, penalty, and interest due (Total of Lines 17, 18, and 19) ...................................................
00
AGRICULTURE INSPECTION FEE — ROUND TO WHOLE GALLONS AND DOLLARS
21
21. Gallons subject to agriculture inspection fee (Total from Line 10, Columns A and B) ............
$
22
22. Total of inspection fee due (Line 21 times $0.025 cents per 50 gallons) ...............................................................
00
$
23
23. Penalty (5% per month up to 25% of total fee due) ................................................................................................
00
$
24
24. Interest for late payment (see interest information on instructions) ........................................................................
00
$
25
25. Total agriculture inspection fee, penalty, and interest due (Total of Lines 22, 23, and 24) ...........................
00
TRANSPORT LOAD FEE — ROUND TO WHOLE GALLONS AND DOLLARS
26
26. Gallons subject to transport load fee (Total from Line 21) ......................................................
27
27. Deduct gallons sold to airline companies and railroad corporations ......................................
28
28. Total gallons on which transport load fee is due (Line 26 minus Line 27) ..............................
$
29
29. Total of transport load fee due (Line 28 times $20.00 per 8,000 gallons) ..............................................................
00
$
30
30. Penalty (5% per month up to 25% of total fee due) ................................................................................................
00
$
31. Interest for late payment (see interest information on instructions) ........................................................................
31
00
32
$
32. Total transport load fee, penalty, and interest due (Total of Lines 29, 30, and 31) ........................................
00
$
33. TOTAL PAID WITH VOUCHER (Total Lines 15, 20, 25, and 32) ........................................................................
33
00
If you pay by check, you authorize the Department of Revenue to process the check electronically. Any check returned unpaid may be presented again electronically.
I/We declare under the penalties of perjury that this return including any accompanying schedules and statements has been examined by me/us and to the best of my/our know ledge, and belief it
is a true, correct and complete return made in good faith for the taxable period stated, pursuant to existing laws requiring the filing of this return.
NAME (PRINT)
SIGNATURE
TELEPHONE NUMBER
DATE
(__ __ __) __ __ __ - __ __ __ __
__ __ / __ __ / __ __ __ __
(09-2011)
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