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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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
00
2. Tax due (Line 1 times $ 0.17) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
00
3. Penalty due (Line 2 times 5% per month up to 25%) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
00
4. Interest due (Line 2 times 8% per annum) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
00
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).