DLN
MISSOURI DEPARTMENT OF REVENUE
FORM
TAXATION DIVISION
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1531
P.O. BOX 300
JEFFERSON CITY, MO 65105-0300
(573) 751-7671
TDD 1-800-735-2966
(REV. 02-2011)
GASOLINE DELIVERED FOR MARINE USE
DISTRIBUTOR NAME/ADDRESS
DISTRIBUTOR MONTHLY REPORT OF MOTOR
VEHICLE FUEL DELIVERED FOR MARINE USE.
(This report must be filed in addition to the
Distributor’s Monthly Tax Report covering gaso-
line, if marine use fuel is delivered in any of the
qualifying counties listed on the back of this form.)
REPORTING MONTH/YEAR
___ ___ / ___ ___ ___ ___
DISTRIBUTOR’S LICENSE NUMBER
IMPORTANT NOTES
1. A copy of the invoice for each delivery must accompany this report. Group all invoices by county and secure as a group with fastener.
2. Do not send any payment with this report.
3. If additional space is needed, use blank sheet and identify columns as below.
If you have questions or need assistance in completing this form, please call this office at (573) 751-7671 or e-mail excise@dor.mo.gov. You may also
obtain a copy of this form from the Department’s web site:
.
I. Enter name of each qualifying
II. Enter total number of deliveries
III. Enter total gallons of gasoline
IV. Enter total dollar amount of
county in which a delivery was
made in each qualifying county for
delivered in qualifying county
motor fuel tax collected on
made. (See reverse side.)
marine use. (See reverse side.)
for marine use.
gasoline shown in Column III.
I, the undersigned, upon my oath, declare that the statements made hereon and the invoices attached including the copies of the delivery tickets are true and
correct to the best of my knowledge.
NAME
TITLE
DATE
__ __ / __ __ / __ __ __ __
MO 860-1176 (02-2011)
DEPARTMENT OF REVENUE’S COPY
This publication is available upon request in alternative accessible format(s).