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Document Locator Number (Department Use Only)
Form
Missouri Department of Revenue
8A
Affidavit for Bad Debt Loss
Name
License Number
Federal Employer Identification Number (FEIN)
Month and Year
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Address
P.O. Box
City
State
ZIP Code
Telephone Number
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Attach copies of all documents identified below. Supplier credit is limited to the amount due from the purchaser and any amount accruing for a period not to exceed ten days
or the date of notification to the director, whichever is earlier following the date of failure to make payment. Round to whole dollars.
Eligible Purchaser
Document
Selling Date
Gallons
Product
Tax or Fee Rate
Eligible Purchaser’s Name
Total Amount Claimed
License Number
Number
(MM/DD/YYYY)
Invoiced
Type
Charged
$
00
__ __ / __ __ / __ __ __ __
$
00
__ __ / __ __ / __ __ __ __
$
00
__ __ / __ __ / __ __ __ __
$
00
__ __ / __ __ / __ __ __ __
$
00
__ __ / __ __ / __ __ __ __
$
00
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$
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$
00
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$
00
__ __ / __ __ / __ __ __ __
$
00
__ __ / __ __ / __ __ __ __
0
Total Amount Claimed For Credit
$
00
Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct.
Signature
Printed Name
Title
Date (MM/DD/YYYY)
__ __ /__ __ /__ __ __ __
Form 8A (Revised 04-2014)
Mail To:
Taxation Division
Phone: (573) 751-2611
P.O. Box 300
Fax: (573) 522-1720
Visit
for additional information.
Jefferson City, MO 65105-0300
TTY: (800) 735-2966
E-mail:
excise@dor.mo.gov