Form 574 - Distributor'S Schedule Of Receipts Page 2
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2INSTRUCTIONS FOR DISTRIBUTOR’S SCHEDULE OF RECEIPTS
General Instructions
This schedule provides detail in support of the amount(s) shown as receipts on Form 4757, Distributor’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 (573) 751-2611 or e-mail excise@dor.mo.gov. You may also access the department’s web site at
to obtain this form.
Identifying Information
Company Name, License Number, and FEIN:
Enter the name and numbers for the distributor shown on the distributor report.
Schedule Type:
Enter one of the following numbers:
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
2B. Gallons of blend stock received tax and/or fees unpaid
2G. Gallons of clear kerosene received fees paid (for sale through barricaded pumps)
Column Instructions
Columns 1 and 2:
Name of Carrier — Enter the name and FEIN of the company that transports the product.
Column 3:
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
Column 4:
Point of Origin/Destination — Enter the location the product was transported from/to. When received into or from a terminal, use the IRS Terminal
Control Code.
Columns 5 and 6:
Seller’s Name and FEIN — Enter the name and FEIN of the company the product was acquired from.
Column 7:
Date Received — Enter the date the product was received.
Column 8:
Document Number — Enter the identifying number from the document issued at the terminal when product is removed from the rack.
Column 9:
Net Gallons — Enter the net amount of gallons received.
Column 10:
Gross Gallons — Enter the gross amount of gallons received.
Column 11:
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 Form 4757, Distributor’s Monthly Tax Report.)
MO 860-1111 (11-2006)
DOR-574 (11-2006)
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