Form 4758 - Schedule Of Supplier State Diversion Corrections
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MISSOURI DEPARTMENT OF REVENUE
DLN
FORM
TAXATION BUREAU
4758
P.O. BOX 300, JEFFERSON CITY, MISSOURI 65105-0300
(573) 751-2611
TDD (800) 735-2966
PAGE
(REV. 11-2006)
SCHEDULE OF SUPPLIER STATE DIVERSION CORRECTIONS
OF
SEE INSTRUCTIONS ON REVERSE SIDE
SUPPLIER’S NAME
LICENSE NUMBER
FEIN
SCHEDULE TYPE
MONTH, YEAR
11
PRODUCT TYPE — Complete a separate schedule for each product type
CIRCLE ONE
065 — Gasoline
125 — Aviation Gasoline
160 — Clear Diesel Fuel
290 — Bio-Diesel – Dyed B100
123 — Alcohol
130 — Jet Fuel
228 — Dyed Diesel Fuel
122 — Blending Components
241 — Ethanol
142 — Clear Kerosene
284 — Bio-Diesel – Undyed B100
(Identify)
124 — Gasohol
072 — Dyed Kerosene
285 — Soy Oil
4
1
2
3
5
6
7
8
9
10
11
12
13
ORIGINAL
NAME OF CARRIER
CARRIER’S
MODE
REVISED
TERMINAL
PURCHASER’S NAME
PURCHASER’S
DATE
DOCUMENT
NET
GROSS
INVOICED
DIVERSION
DEST. STATE
FEIN
DEST. STATE
CODE
FEIN
SHIPPED
NUMBER
GALLONS
GALLONS
GALLONS
NUMBER
PAGE TOTAL
SCHEDULE TOTAL
This form is available upon request in alternative accessible format(s).
MO 860-2837 (11-2006)
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