Fillable Printable Form 574 - Distributor'S Schedule Of Receipts

Form 574 - Distributor'S Schedule Of Receipts

Form

574

Missouri Department of Revenue

Distributor’s Schedule of Receipts

Explanation

Mail to: Taxation Division Phone: (573) 751-2611

P.O. Box 300 TTY: (800) 735-2966

Jefferson City, MO 65105-0300 Fax: (573) 522-1720

E-mail: [email protected]

Visit http://dor.mo.gov/business/fuel/ for additional information.

Form 574 (Revised 09-2017)

1. Gallons received in Missouri tax and/or fees paid

1B. Gallons received for export, destination state tax, and/or fees paid

1C. Gallons received tax and/or fees paid with an import payment voucher

1E. Gallons imported from another state, Missouri tax, and/or fees paid

2A. Gallons received tax and/or fees unpaid—provide explanation below. (e.g., tank

wagon imports and untaxed alcohol or Bio-Diesel — Undyed B100)

2B. Gallons of blend stock received tax and/or fees unpaid.

2G. Gallons of clear kerosene received fees paid (for sale through barricaded pumps)

Schedule Type

r 065 — Gasoline r 228 — Dyed Diesel Fuel

r 072 — Dyed Kerosene r 284 — Bio-Diesel – Undyed B100

r 123 — Alcohol r 285 — Soy Oil

r 241 — Ethanol r 290 — Bio-Diesel – Dyed B100

r 124 — Gasohol r 224 — Compressed Natural Gas (CNG)

r 125 — Aviation Gasoline r 225 — Liquefied Natural Gas (LNG)

r 130 — Jet Fuel r 054 — Propane

r 142 — Clear Kerosene r 122 — Blending Components (Identify) ___________

r 160 — Clear Diesel Fuel

Select one and complete a separate schedule for each product type

Product Type

Name of Carrier

Carrier’s FEIN

Mode

Origin Dest.

Point of

Seller’s Name

Seller’s

FEIN

Date

Received

Document

Number

Net Gallons

Gross

Gallons

Invoiced

Gallons

Page Total

Schedule Total

__ __ / __ __ / __ __ __ __

Schedule

__ __ / __ __ / __ __ __ __

Page

Distributor’s Name License Number Federal Employer Identification Number (FEIN) Schedule Type Month, Year (MM/YYYY)

__ __ / __ __ __ __

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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.

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)

Instructions