Form 2994 - Schedule Of Supplier Or Permissive Supplier Terminal Rack Removals Page 2
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2This schedule(s) provides detail in support of the amount(s) shown as disbursements on Supplier or Permissive Supplier’s Monthly Tax Report
(Form
572).
Each disbursement of product should be listed on separate lines. Complete a separate schedule for each product type.
Columns 1 and 2:
Name of Carrier — Enter the name and FEIN of the company that transports the product from the terminal.
Column 3:
Mode of Transport — Enter the mode of transport from the terminal. Use one of the following:
J = Truck
R = Rail
B = Barge
PL = Pipeline
BA = Book Adjustment
ST = Stationary Transfer
Column 4:
Point of Origin or Destination — Enter the location the product was transported from and to.
Column 5:
Terminal Code — IRS Terminal Control Code.
Columns 6 and 7:
Sold To — Enter the name and FEIN of the company the product was sold to.
Column 8:
Date Shipped — Enter the date the product was shipped.
Column 9:
Document Number — Enter the identifying number from the document issued at the terminal when product is removed from the rack. In
case of pipeline or barge movements, enter the pipeline or barge ticket number.
Columns 10 and 11:
Net and Gross Gallons — Enter the net and gross amount of gallons of product disbursed.
Column 12:
Invoiced Gallons — Enter the number of gallons billed to the customer. (Should equal either net or gross.)
(Use these figures to complete Worksheet on reverse side, Supplier or Permissive Supplier’s Monthly Tax Report (Form 572).
Form 2994 (Revised 01-2016)
Mail To:
Taxation Division
Phone: (573) 751-2611
P.O. Box 300
Fax: (573) 522-1720
Visit
for additional information.
Jefferson City, MO 65105-0300
TDD: (800) 735-2966
E-mail:
excise@dor.mo.gov
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