Fillable Printable Form 573 - Schedule Of Supplier Tax-Paid Receipts
Fillable Printable Form 573 - Schedule Of Supplier Tax-Paid Receipts
Form 573 - Schedule Of Supplier Tax-Paid Receipts
Form
573
Missouri Department of Revenue
Schedule of Supplier Tax-Paid Receipts
Mail to: Taxation Division Phone: (573) 751-2611
P.O. Box 300 Fax: (573) 522-1720
Jefferson City, MO 65105-0300 TTY: (800) 735-2966
E-mail: [email protected]
Form 573 (Revised 01-2016)
Visit
http://www.dor.mo.gov/business/fuel/
for additional information.
Document Locator Number
Page _______ of _______
Supplier’s Name License Number Schedule Type Federal Employer I.D. Number Month and Year
1 __ __ /__ __ __ __
Select One (Complete a separate schedule for each product type)
r 065 - Gasoline r 124 - Gasohol r 142 - Clear Kerosene r 284 - Bio-Diesel - Undyed B100 r 285 - Soy Oil
r 123 - Alcohol r 125 - Aviation Gasoline r 072 - Dyed Kerosene r 228 - Dyed Diesel Fuel r 225 - Liquefied Natural Gas
r 241 - Ethanol r 130 - Jet Fuel r 160 - Clear Diesel Fuel r 290 - Bio-Diesel - Dyed B100 r 122 - Blending Components
(Identify) _____________
Product Type
Name of Carrier
Carrier’s
FEIN
Mode
Origin Dest.
Point of
Seller’s Name
Seller’s
FEIN
Date
Shipped
Document
Number
Net
Gallons
Gross
Gallons
Invoiced
Gallons
Page Total
Schedule Total
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This schedule(s) provides detail in support of the amount(s) shown as tax-paid receipts on Form 572, Supplier and Permissive Supplier’s Monthly Tax
Report.
Each receipt of product should be listed on a separate line. Complete a separate schedule for each product type.
If you have questions or need assistance in completing this form, please call contact us.
Identifying Information
Company Name, License Number and FEIN: Enter the name and numbers for the supplier shown on the supplier report.
Column Instructions
Carrier Name and FEIN : Enter the name and FEIN of the company that transports the product.
Mode: Mode of Transport — Enter the mode of transport from the terminal. Use one of the following:
J = Truck R = Rail B = Barge PL = Pipeline
BA = Book Adjustment ST = Stationary Transfer
Point of Origin and Destination: Enter the location the product was transported from/to. When received into or from a terminal, use the IRS Terminal
Control Code.
Seller Name and FEIN: Enter the name and FEIN of the company the product was acquired from.
Date Shipped: Enter the date the product was received.
Document Number: Enter the identifying number from the document issued at the terminal when product is removed from the rack. In case of
pipeline or barge movements, enter the pipeline or barge ticket number.
Net Gallons: Enter the net amount of gallons received.
Gross Gallons: Enter the gross amount of gallons received.
Invoiced Gallons: Enter the number of gallons billed (should equal either net or gross gallons).
Use these figures to complete the worksheet on reverse side of Form 572, Supplier and Permissive Supplier’s Monthly Tax Report, Line 4A.
Instructions
Form 573 (Revised 01-2016)
