Form 4783 - Consumer Payment Voucher Page 2
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1
2Consumer Payment Voucher
Instructions
When is a Consumer Payment Voucher to Be Used?
Use a consumer payment voucher when the consumer has purchased tax-exempt fuel and used it for a taxable purpose or when the
consumer knows that the fuel tax was not precollected.
When is the Payment Due?
The payment of taxes will be due on the last day of the month for any purchases made in the preceding calendar month.
Completing the Voucher
General Information:
Complete each line on the top portion of the voucher. Be sure to include all information requested.
Round to whole gallons and whole dollars.
Listing Purchase Information:
Provide all requested information for all gallons purchased tax-exempt and used for a taxable purpose.
Calculating Tax (Line 2):
Multiply the total taxable gallons (Line 1) (x) $0.17 to calculate the tax due.
Penalty (Line 3):
Calculate any penalty due by multiplying the total tax due (Line 2) by 5 percent per month up to 25 percent of the total tax due.
Interest (Line 4):
Calculate any interest due by multiplying the total tax due (Line 2) by 8 percent. Divide this number by 365 (366 in a leap year) and
multiply the result by the number of days payment is late.
Total Paid (Line 5):
Add Lines 2, 3, and 4 for the total paid on voucher.
Mailing the Voucher and Remittance:
Make the check payable to the Missouri Department of Revenue and mail to the Missouri Department of Revenue, Taxation Bureau,
Excise Tax, P.O. Box 300, Jefferson City, MO 65105-0300.
If you have questions or need assistance in completing this form, please call (573) 751-2611 or e-mail excise@dor.mo.gov. You may
also access the department’s web site at to obtain this form.
MO 860-2849 (11-2006)
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Parent category: Financial