Form 4758 - Schedule Of Supplier State Diversion Corrections
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Page _______ of _______
Document Locator Number
Form
Missouri Department of Revenue
4758
Schedule of Supplier State Diversion Corrections
Supplier’s Name
License Number
FEIN
Schedule Type
Month and Year
11
__ __ /__ __ __ __
Complete a separate schedule for each product type.
r
r
r
r
Select One
065 - Gasoline
125 - Aviation Gasoline
072 - Dyed Kerosene
225 - Liquefied Natural Gas
r
r
r
r
124 - Gasohol
142 - Clear Kerosene
160 - Clear Diesel Fuel
228 - Dyed Diesel Fuel
Carrier’s
Original
Revised
Terminal
Date Shipped
Document
Net
Gross
Invoiced
Diversion
Name of Carrier
Purchaser’s Name
Purchaser’s FEIN
Mode
FEIN
Dest. State
Dest. State
Code
Number
Gallons
Gallons
Gallons
Number
(MM/DD/YYYY)
Page Total
Mail to: Taxation Division
Phone: (573) 751-2611
Visit
P.O. Box 300
Fax: (573) 522-1720
Schedule Total
for additional information.
Jefferson City, MO 65105-0300
TTY: (800) 735-2966
Form 4758 (Revised 01-2016)
E-mail:
excise@dor.mo.gov
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