Form 591 - Supplier Delinquent Tax Collection

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DLN
MISSOURI DEPARTMENT OF REVENUE
TAXATION DIVISION
FORM
P.O. BOX 300, JEFFERSON CITY, MO 65105-0300
591
(573) 751-2611 TDD (800) 735-2966
SUPPLIER DELINQUENT
(REV. 09-2011)
PAGE
TAX COLLECTION
OF
SEE INSTRUCTIONS ON REVERSE SIDE — ROUND TO WHOLE GALLONS AND DOLLARS
SUPPLIER’S NAME
LICENSE NUMBER
FEIN
MONTH/YEAR
__ __ / __ __ __ __
__ __ __ __ __ __ __ __ __
ELIGIBLE PURCHASER INFORMATION
ELIGIBLE PURCHASER’S NAME
LICENSE NUMBER
FEIN
___ ___ ___ ___ ___ ___ ___ ___ ___
PRODUCT TYPE — (Complete a separate schedule for each product type.)
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
SECTION 1 — DELINQUENT TAX — ROUND TO WHOLE GALLONS AND DOLLARS
Invoice
Invoiced
Document Number
Tax Rate
Tax Amount
Penalty
Interest
Total Collected
Date
Gallons
_ _ / _ _ / _ _ _ _
$
00
$
00
$
00
$
00
_ _ / _ _ / _ _ _ _
$
00
$
00
$
00
$
00
_ _ / _ _ / _ _ _ _
$
00
$
00
$
00
$
00
_ _ / _ _ / _ _ _ _
$
00
$
00
$
00
$
00
_ _ / _ _ / _ _ _ _
$
$
$
$
00
00
00
00
TOTAL
$
00
$
00
$
00
$
00
SECTION 2 — DELINQUENT INSPECTION FEE — ROUND TO WHOLE GALLONS AND DOLLARS
Invoice
Invoiced
Document Number
Fee Rate
Fee Amount
Penalty
Interest
Total Collected
Date
Gallons
_ _ / _ _ / _ _ _ _
00
00
00
00
$
$
$
$
00
00
00
00
_ _ / _ _ / _ _ _ _
$
$
$
$
00
00
00
00
_ _ / _ _ / _ _ _ _
$
$
$
$
_ _ / _ _ / _ _ _ _
00
00
00
00
$
$
$
$
_ _ / _ _ / _ _ _ _
00
00
00
00
$
$
$
$
TOTAL
00
00
00
00
$
$
$
$
SECTION 3 — DELINQUENT TRANSPORT LOAD FEE — ROUND TO WHOLE GALLONS AND DOLLARS
Invoice
Invoiced
Document Number
Fee Rate
Fee Amount
Penalty
Interest
Total Collected
Date
Gallons
_ _ / _ _ / _ _ _ _
00
00
00
00
$
$
$
$
_ _ / _ _ / _ _ _ _
00
00
00
00
$
$
$
$
00
00
00
00
_ _ / _ _ / _ _ _ _
$
$
$
$
00
00
00
00
_ _ / _ _ / _ _ _ _
$
$
$
$
_ _ / _ _ / _ _ _ _
00
00
00
00
$
$
$
$
TOTAL
00
00
00
00
$
$
$
$
SECTION 4 — DELINQUENT POOL BOND — ROUND TO WHOLE GALLONS AND DOLLARS
Invoice
Invoiced
Document Number
Bond Rate
Bond Amount
Penalty
Interest
Total Collected
Date
Gallons
_ _ / _ _ / _ _ _ _
00
00
$
$
_ _ / _ _ / _ _ _ _
00
00
$
$
_ _ / _ _ / _ _ _ _
00
00
$
$
00
00
_ _ / _ _ / _ _ _ _
$
$
TOTAL
00
00
$
$
NAME (PLEASE PRINT)
SIGNATURE
DATE
_ _ / _ _ / _ _ _ _
(09-2011)

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