Form                                                                                                                                                         Print Form                   Reset Form
                                   Distributor’s Schedule of Receipts
                              574
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Distributor’s Name                                                                                           License Number                   Federal Employer Identification Number (FEIN)  Schedule Type          Month, Year (MM/YYYY)
                                                                                                                                                                                                                    __ __ / __ __ __ __
                                                                                                                                                 Select one and complete a separate schedule for each product type
                              1. Gallons received in Missouri tax and/or fees paid
                                                                                                                                              r    065 — Gasoline        r                 228 —  Dyed Diesel Fuel
                              1B.  Gallons received for export, destination state tax, and/or fees paid
                                                                                                                                              r  072 — Dyed Kerosene     r                 284 —  Bio-Diesel  – Undyed B100
                              1C.  Gallons received tax and/or fees paid with an import payment voucher                                       r  123 — Alcohol           r                 285 —  Soy Oil
                              1E.  Gallons imported from another state, Missouri tax, and/or fees paid                                        r  241 — Ethanol           r                 290 —  Bio-Diesel – Dyed B100
                              2A.   Gallons received tax and/or fees unpaid—provide explanation below.  (e.g., tank                           r  124 — Gasohol           r                 224 —  Compressed Natural Gas (CNG)
                                                                                                                                              r  125 — Aviation Gasoline r                 225 —  Liquefied Natural Gas (LNG)
                Schedule Type    wagon imports and untaxed alcohol or Bio-Diesel — Undyed B100)                                   Product Type
                              2B.  Gallons of blend stock received tax and/or fees unpaid.                                                    r  130 — Jet Fuel          r                 054 — Propane
                                                                                                                                              r  142 — Clear Kerosene    r                 122 —  Blending Components (Identify) ___________ 
                              2G.  Gallons of clear kerosene received fees paid (for sale through barricaded pumps)                           r  160 — Clear Diesel Fuel 

                                 Name of Carrier Carrier’s FEIN Mode                       Point of                 Seller’s Name                Seller’s          Date                    Document  Net Gallons    Gross      Invoiced 
                                                                                  Origin               Dest.                                     FEIN              Received                Number                   Gallons    Gallons

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        Schedule
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                                                                                                                                                                                           Page Total             0          0         0
                                                                                                                                                                         Schedule Total
Explanation

                                                                                                                                                                                                                    Form 574 (Revised 09-2017)
Mail to:  Taxation Division                                      Phone: (573) 751-2611
                                   P.O. Box 300                  TTY: (800) 735-2966                                Visit http://dor.mo.gov/business/fuel/ for additional information.
                                   Jefferson City, MO 65105-0300 Fax: (573) 522-1720
                                                                 E-mail:  excise@dor.mo.gov  

This schedule provides detail in support of the amount(s) shown as receipts on the Distributor’s Monthly Tax Report (Form 4757).
Each receipt of product should be listed on a separate line.  Complete a separate schedule for each product type.
  You may access the Department’s website at http://dor.mo.gov/forms/index.php?category=18 to obtain this form.

Name of Carrier  —  Enter the name of the company that transports the product.
Carrier’s FEIN  — Enter the FEIN of the company that transports the product.
Mode of Transport  —  Enter the mode of transport from the terminal.  Use one of the following:
 B = Barge BA = Book Adjustment J = Truck PL = Pipeline
 R = Rail ST = Stationary Transfer
Point of Origin or Destination  —  Enter the location the product was transported to or from.  When received into or from a terminal, use the IRS Terminal Control Code.
Seller’s Name  —  Enter the name of the company the product was acquired from.
Instructions
Seller’s FEIN  —  Enter the FEIN of the company the product was acquired from.
Date Received  —  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.
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 worksheet on reverse side of Distributor’s Monthly Tax Report (Form 4757).

Form 574 (Revised 09-2017)