Form 2994 - Schedule Of Supplier Or Permissive Supplier Terminal Rack Removals
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Document Locator Number (Department Use Only)
Form
Missouri Department of Revenue
2994
Schedule of Supplier or Permissive
Supplier Terminal Rack Removals
Supplier’s Name
License Number
Federal Employer Identification Number (FEIN)
Schedule Type
Month and Year
Page
___ ___ / ___ ___ ___ ___
of
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Select One:
r
5A. Gallons sold from in-state terminals.
Select One:
r
r
r
160 — Diesel Fuel
5B. Gallons sold for import from state of ____________ .
065 — Gasoline
r
r
5F. Gallons of dyed diesel sold for taxable purposes from in-state terminals (Missouri tax collected).
r
228 — Dyed Diesel Fuel
123 — Alcohol
r
5G. Gallons of dyed diesel sold for taxable purposes for import from state of _____________
r
r
284 — Bio-Diesel – Undyed B100
241 — Ethanol
(Missouri tax collected).
r
285 — Soy Oil
r
r
124 — Gasohol
5H. Gallons sold for export to state of ___________________ destination state tax paid. (2 copies)
r
r
r
290 — Bio-Diesel – Dyed B100
6. Gallons delivered to distributors — tax not collected (jet fuel, alcohol, Bio-Diesel – Undyed B100,
125 — Aviation Gasoline
r
r
225 — Liquefied Natural Gas (LNG)
blending components and undyed kerosene for non-highway use)
142 — Kerosene
r
r
7. Gallons exported to state of ____________________ by supplier. (2 copies)
r
122 — Blending Components
130 — Jet Fuel
r
8. Gallons delivered to U.S. government — tax exempt.
r
(Identify)
072 — Dyed Kerosene
r
10. Gallons delivered to other tax exempt entities (airlines, railroads and barges; not applicable to LNG)
r
10D. Credit card sales to U.S. government.
r
10U. Gallons fees exempt. (LNG Only)
5
8 Date
10
11
12
4 Point Of
1 Name of
6 Sold
7 Purchaser’s
3
9 Document
2 Carrier’s
Terminal
Shipped
Net
Gross
Invoiced
Carrier
To
FEIN
Mode
Number
FEIN
Code
(MM/DD/YYYY)
Gallons
Gallons
Gallons
Origin Dest.
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0
0
0
Page Total
Schedule Total
Form 2994 (Revised 01-2016)
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Parent category: Financial