Missouri Propane Education and Research Council, Inc.
4110 Country Club Dr.
Jefferson City, MO 65109
Phone: (573) 893-8298 Fax: (573) 893-2623
Federal Identification No. 431702395
PROPANE USAGE REPORT
FOR CALENDAR MONTH/YEAR __________________________
PURCHASER: COMPANY NAME & ADDRESS TOTAL GALLONS TOTAL ASSESMENT
5/10th of one cent per gallon
No propane sold during this month.
Assessments are in accordance with 414.500-414.590 RSMo and are due by the 25th of the month
following the month of collection. To wit: 4/10 cent is designated for use by Missouri Propane
Education and Research Council; 1/10 cent is designated for use by Missouri Propane Gas Commission.
I certify that the above information is true and correct.
Signature & Title Date
Company Name & Phone #