Fillable Form 575 - Terminal Operator Report printable pdf download

Form 575 - Terminal Operator Report

Download a blank fillable Form 575 - Terminal Operator Report in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form 575 - Terminal Operator Report with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

DLN

MISSOURI DEPARTMENT OF REVENUE

FORM

Reset Form

Print Form

TAXATION DIVISION

P.O. BOX 300

575

JEFFERSON CITY, MO 65105-0300

(573) 751-2611

TDD 1-800-735-2966

(REV. 02-2011)

TERMINAL OPERATOR REPORT

TERMINAL

NAME OF TERMINAL

MONTH/YEAR

CHECK HERE

IF AMENDED

IF ADDITIONAL

__ __ / __ __ __ __

REPORT

LOCATION OF TERMINAL

TERMINAL CODE

CITY

STATE

ZIP

___ ___ ___ ___ ___

OPERATOR

COMPANY NAME

LICENSE NUMBER

FEIN

___ ___ ___ ___ ___ ___ ___ ___ ___

STREET ADDRESS

PO BOX

CITY

STATE

ZIP

TELEPHONE NUMBER

FAX NUMBER

___ ___ ___ ___ ___

(___ ___ ___) ___ ___ ___ - ___ ___ ___ ___

TRANSACTION

COLUMN D

COLUMN E

COLUMN F

COLUMN H

COLUMN A

COLUMN B

COLUMN C

COLUMN G

TRANSACTION FOR THE MONTH

AVIATION

UNDYED DIESEL &

DYED DIESEL &

BLENDING

GASOLINE

ALCOHOL

GASOHOL

JET FUEL

GASOLINE

KEROSENE

COMPONENTS

1. Beginning Inventory (Previous month’s ending

inventory)

2. Total Receipts (From Terminal Receipts

Schedule TR plus 2X)

3. Total Gallons Available (Line 1 plus Line 2)

4. Total Disbursements (From Terminal

Disbursement Schedule TD plus 6X)

5. Gallons Available (Line 3 minus Line 4)

6. Stock Gains & Losses (+ or -)

7. Actual Ending Inventory

I do hereby certify under penalty of perjury that the foregoing and attached reports are a true and correct statement to the best of my knowledge and is a complete and full presentation

of all transactions from the best information available.

PRINT NAME

SIGNATURE

TITLE

DATE

__ __ / __ __ /__ __ __ __

Mail report and payment to: Missouri Department of Revenue, Taxation Division, Excise Tax, P.O. Box 300, Jefferson City, MO 65105-0300.

This publication is available upon request in alternative accessible format(s).

MO 860-1112 (02-2011)