Fill in a Valid Missouri 4757 Template

COMPANY NAME

STREET ADDRESS

CITY

PRINT NAME

SIGNATURE

TITLE

DATE

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This report and its supporting schedules must be fully completed and mailed to the Missouri Department of Revenue along with any tax and/or fees due on the last day of each month for the purchases made in the preceding calendar month unless such day falls on a weekend or state holiday in which case the report, tax, and fees would be due the next succeeding business day. A report is due whether or not there were any activity during the month. You may access the due date schedule at http://dor.mo.gov/business/fuel/.

Original reports and schedules must contain all the required information. Computer generated reports and schedules, approved by the Department, must contain all the information required on the original reports and schedules.

Correcting Reports

Additional Report - adds or takes away any additional gallons from the original report. When filing an additional report, please report only those gallons in which you are changing.

Amended Report - filed when all or the majority of the information originally reported is incorrect. This type of report will replace all information that was first reported.

YOU MUST ROUND TO WHOLE GALLONS AND DOLLARS (Example: Round down if less than .50 and round up if .50 to .99)

Taxable Gallons (Round to whole gallons)

1.Gallons of blend stock received tax and/or fees unpaid (From worksheet, Line 6).

2.Gallons of fuel received in Missouri tax and/or fees unpaid. Attach an explanation with Schedule 2A (From worksheet, Line 5). Tank wagon operators report fuel imported into Missouri on this line.

3.Gallons of tax exempt product blended (For taxable use) (From worksheet, Line 17).

4.Gallons of dyed fuel sold for taxable purposes (From worksheet, Line 11).

5.Gallons subject to tax and/or fees (Total of Lines 1, 2, 3, and 4).

6.Gallons of fuel exported (Missouri tax and/or fees paid) (From worksheet, Line 14).

7.Calculate allowance. Line 6 times (X) the appropriate percentage. (Applies only when supplier passed allowance to purchaser of Missouri tax paid fuel.)

8.Net gallons exported of Missouri tax paid fuel. (Line 6 minus (–) Line 7).

9.Net gallons subject to tax and/or fees (Line 5 minus (–) Line 8).

Tax Calculation (Round to whole dollars)

Tax rate for gasoline, alcohol blended with gasoline, gasohol and other products blended with gasoline, clear diesel, clear kerosene and other products blended with clear diesel or clear kerosene is $0.17 per gallon. Aviation gasoline tax rate is $0.09 per gallon.

10.Tax due is based on the taxable gallons times (X) the appro- priate tax rates (Line 9 times (X) $0.17 or $0.09).

11.If you have a motor fuel tax credit from a previous report, you will receive a letter. Enter the amount of your motor fuel tax credit and attach a copy of the authorization.

12.Total motor fuel tax due (Line 10 minus Line 11).

Inspection Fee (Round to whole dollars)

13.Total gallons subject to inspection fee (From worksheet, Lines 5, 6, 17, and 17A).

14.Gallons of fuel exported fees paid (From worksheet, Line 14).

15.Gallons subject to inspection fee (Line 13 minus (–) Line 14).

16.Inspection fee due (Line 15 times (X) .0005).

17.If you have an inspection fee credit from a previous report, you will receive a letter. Enter the amount of your inspection fee credit and attach a copy of the authorization.

18.Total inspection fee due (Line 16 minus Line 17).

Transport Load Fee (Round to whole dollars)

19.Total gallons of fuel subject to transport load fee (Line 15 above).

20.Motor fuel gallons sold to railroad corporations, airline companies or used as bunker fuel in vessels are not subject to the transport load fee (Total from attached Schedule 10K, 10R, or 10Y).

21.Total gallons subject to transport load fee (Line 19 minus (–) Line 20).

22.Transport load fee (Line 21 times (X) 0.0025).

23.If you have a transport load fee credit from a previous report, you will receive a letter. Enter the amount of your transport load fee credit and attach a copy of the authorization.

24.Total transport load fee due (Line 22 minus Line 23).

Taxes and Fees Due (Round to whole dollars)

25.Total motor fuel tax due (total from Line 12 Columns A, B, C, E, and F).

26.Total aviation gasoline tax due (Total from Line 12 Column D).

27.Total inspection fee due (Total from Line 18).

28.Total transport load fee due (Total from Line 24).

29.Total taxes and fees due (Lines 25, 26, 27, and 28).

Penalty (Round to whole dollars)

30.If your report is not filed on a timely basis or taxes are not paid timely (filed and received by the United States Post Office cancellation stamped upon the envelope), you are subject to a penalty of five percent per month up to 25 percent of the total amount of tax (Line 29 times (X) penalty amount, 5 percent up to 25 percent).

Interest (Round to whole dollars)

31. Interest is due on any late payment (Line 29 times ( X ) t h e a n n u a l i n t e r e s t r a t e , m u l t i p l i e d b y (X ) t h e number of days late divided by 365 (366 for leap years)). The annual interest rate is subject to change each year. You may access the annual interest rate on the Department’s web site at: http://dor.mo.gov.intrates.php.

32. Total taxes, fees, penalty, and interest due (Lines 29, 30, and 31).

Pool Bond Payment (Participants Only) (Round to whole dollars)

33.Pool bond amount due. From Form 4759, Schedule 5T.

34.Total remittance due. Total fuel tax, fees, and pool bond amount due (Total Line 32 plus (+) Line 33).

The total of fuel tax, aviation gasoline fuel tax, inspection fee, transport load fee, and pool bond amount should equal Line 34.

Send your check or money order to the Missouri Depart- ment of Revenue. You may also charge the balance due to Mastercard, Discover, American Express, or Visa by calling toll-free ( 8 8 8 ) 9 2 9 - 0 5 1 3 o r y o u m a y p a y o n l i n e a t