Form 573 - Schedule Of Supplier Tax-Paid Receipts (2011)
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MISSOURI DEPARTMENT OF REVENUE
FORM
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TAXATION DIVISION
573
P.O. BOX 300, JEFFERSON CITY, MO 65105-0300
(573) 751-2611
TDD (800) 735-2966
PAGE
(REV. 02-2011)
SCHEDULE OF SUPPLIER TAX-PAID RECEIPTS
OF
SEE INSTRUCTIONS ON REVERSE SIDE
SUPPLIER’S NAME
LICENSE NUMBER
FEIN
SCHEDULE TYPE
MONTH, YEAR
1
__ __ __ __ __ __ __ __ __
__ __ / __ __ __ __
PRODUCT TYPE — Complete a separate schedule for each product type
CIRCLE ONE
228 — Dyed Diesel Fuel
290 — Bio-Diesel – Dyed B100
065 — Gasoline
124 — Gasohol
142 — Clear Kerosene
122 — Blending Components
284 — Bio-Diesel – Undyed B100
123 — Alcohol
125 — Aviation Gasoline
072 — Dyed Kerosene
(Identify)
285 — Soy Oil
241 — Ethanol
130 — Jet Fuel
160 — Clear Diesel Fuel
4
2
7
8
9
10
11
1
3
5
6
POINT OF
CARRIER’S
DATE
DOCUMENT
NET
GROSS
INVOICED
NAME OF CARRIER
MODE
SELLER’S NAME
SELLER’S FEIN
FEIN
ORIGIN
DEST.
SHIPPED
NUMBER
GALLONS
GALLONS
GALLONS
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PAGE TOTAL
SCHEDULE TOTAL
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MO 860-1110 (02-2011)
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Parent category: Financial