DLN
MISSOURI DEPARTMENT OF REVENUE
Print Form
Reset Form
FORM
TAXATION DIVISION
587
P.O. BOX 300, JEFFERSON CITY, MISSOURI 65105-0300
(573) 751-2611
TDD (800) 735-2966
PAGE
(REV. 02-2011)
DISTRIBUTOR’S SCHEDULE OF DISBURSEMENTS
OF
SEE INSTRUCTIONS ON REVERSE SIDE
DISTRIBUTOR’S NAME
LICENSE NUMBER
FEIN
SCHEDULE TYPE
MONTH, YEAR
__ __ __ __ __ __ __ __ __
__ __ / __ __ __ __
SCHEDULE TYPE
PRODUCT TYPE (CIRCLE ONE)
5.
Gallons of dyed fuel sold for taxable purposes
065 — Gasoline
160 — Clear Diesel Fuel
5W. Gallons of tax-exempt product blended tax and fees unpaid
123 — Alcohol
228 — Dyed Diesel Fuel
7A. Gallons exported to state of _____________________ (destination state tax paid) (Original and 1 copy)
241 — Ethanol
284 — Bio-Diesel – Undyed B100
7B. Gallons exported to state of _____________________ (Missouri tax paid) (Original and 1 copy)
124 — Gasohol
10A. Gallons of tax-exempt product blended fees unpaid
285 — Soy Oil
10G. Gallons of other authorized tax-exempt sales (alcohol, Bio-Diesel – Undyed B100)
125 — Aviation Gasoline
290 — Bio-Diesel – Dyed B100
10J. Gallons of undyed kerosene delivered to filling stations (barricaded pumps only)
142 — Clear Kerosene
122 — Blending Components
10K. Gallons delivered to airlines
130 — Jet Fuel
(Identify) _____________________
10R. Gallons delivered for use as bunker fuel in vessels
072 — Dyed Kerosene
10Y. Gallons delivered to railroads
4
1
2
3
5
6
7
8
9
10
11
POINT OF
NAME OF CARRIER
CARRIER’S
MODE
SOLD TO
PURCHASER’S
DATE
DOCUMENT
NET
GROSS
INVOICED
FEIN
ORIGIN
DEST.
FEIN
SHIPPED
NUMBER
GALLONS
GALLONS
GALLONS
_ _ _ _ _ _ _ _ _
__ __ __ __ __ __ __ __ __ _ _ / _ _ / _ _ _ _
_ _ _ _ _ _ _ _ _
__ __ __ __ __ __ __ __ __ _ _ / _ _ / _ _ _ _
_ _ _ _ _ _ _ _ _
__ __ __ __ __ __ __ __ __ _ _ / _ _ / _ _ _ _
_ _ _ _ _ _ _ _ _
__ __ __ __ __ __ __ __ __ _ _ / _ _ / _ _ _ _
_ _ _ _ _ _ _ _ _
__ __ __ __ __ __ __ __ __ _ _ / _ _ / _ _ _ _
_ _ _ _ _ _ _ _ _
__ __ __ __ __ __ __ __ __ _ _ / _ _ / _ _ _ _
_ _ _ _ _ _ _ _ _
__ __ __ __ __ __ __ __ __ _ _ / _ _ / _ _ _ _
_ _ _ _ _ _ _ _ _
__ __ __ __ __ __ __ __ __ _ _ / _ _ / _ _ _ _
_ _ _ _ _ _ _ _ _
__ __ __ __ __ __ __ __ __ _ _ / _ _ / _ _ _ _
_ _ _ _ _ _ _ _ _
__ __ __ __ __ __ __ __ __ _ _ / _ _ / _ _ _ _
0
0
PAGE TOTAL
0
SCHEDULE TOTAL
This form is available upon request in alternative accessible format(s).
MO 860-1113 (02-2011)