Fillable Form 4783 - Consumer Payment Voucher printable pdf download

Form 4783 - Consumer Payment Voucher

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DLN

MISSOURI DEPARTMENT OF REVENUE

FORM

TAXATION BUREAU

4783

P.O. BOX 300, JEFFERSON CITY, MISSOURI 65105-0300

(573) 751-2611

TDD (800) 735-2966

POSTMARK DATE

(REV. 11-2006)

CONSUMER PAYMENT VOUCHER

SEE INSTRUCTIONS ON REVERSE SIDE

CONSUMER’S NAME

MONTH/YEAR OF USAGE

STREET ADDRESS

FEIN/SOCIAL SECURITY NUMBER

PO BOX

CITY

STATE

ZIP

TELEPHONE NUMBER

E-MAIL ADDRESS

FAX

PURCHASE INFORMATION — ROUND TO WHOLE GALLONS AND DOLLARS

Total

Location of Purchase

Type of Product

Date of

Gallons

Purchase Price

Name of Retailer

(City, State)

Purchased

Purchase

Purchased

Excluding Tax

TOTAL

TAX CALCULATION — ROUND TO WHOLE GALLONS AND DOLLARS

1. Total gallons purchased . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2. Tax due (Line 1 times $ 0.17) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3. Penalty due (Line 2 times 5% per month up to 25%) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4. Interest due (Line 2 times 8% per annum) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5. Total Due . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

If you pay by check, you authorize the Department of Revenue to process the check electronically. Any check returned unpaid may be presented again electronically.

I declare under the penalties of perjury that this return including any accompanying schedules and statements has been examined by me and to the best of my knowledge and

belief is a true, correct, and complete return made in good faith for the taxable period stated, pursuant to existing laws requiring the filing of this return.

PRINT NAME

AUTHORIZED SIGNATURE

DATE

MO 860-2849 (11-2006)

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