Form 574 - Distributor'S Schedule Of Receipts
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Form
Missouri Department of Revenue
574
Distributor’s Schedule of Receipts
Page
of
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
r
065 — Gasoline
160 — Clear Diesel Fuel
1B. Gallons received for export, destination state tax, and/or fees paid
r
r
072 — Dyed Kerosene
228 — Dyed Diesel Fuel
1C. Gallons received tax and/or fees paid with an import payment voucher
r
r
123 — Alcohol
284 — Bio-Diesel – Undyed B100
1E. Gallons imported from another state, Missouri tax, and/or fees paid
r
r
241 — Ethanol
285 — Soy Oil
r
r
2A. Gallons received tax and/or fees unpaid—provide explanation below. (e.g., tank
124 — Gasohol
290 — Bio-Diesel – Dyed B100
wagon imports and untaxed alcohol or Bio-Diesel — Undyed B100)
r
r
125 —Aviation Gasoline
224 — Compressed Natural Gas (CNG)
2B. Gallons of blend stock received tax and/or fees unpaid.
r
r
130 — Jet Fuel
225 — Liquefied Natural Gas (LNG)
2G. Gallons of clear kerosene received fees paid (for sale through barricaded pumps)
r
r
142 —Clear Kerosene
122 — Blending Components (Identify) ___________
Point of
Name of Carrier
Carrier’s FEIN Mode
Seller’s
Date
Net Gallons
Invoiced
Seller’s Name
Document
Gross
FEIN
Gallons
Received
Gallons
Number
Origin
Dest.
__ __ / __ __ / __ __ __ __
__ __ / __ __ / __ __ __ __
__ __ / __ __ / __ __ __ __
__ __ / __ __ / __ __ __ __
__ __ / __ __ / __ __ __ __
__ __ / __ __ / __ __ __ __
__ __ / __ __ / __ __ __ __
__ __ / __ __ / __ __ __ __
__ __ / __ __ / __ __ __ __
0
0
0
Page Total
Schedule Total
Explanation
Form 574 (Revised 01-2016)
Mail to:
Taxation Division
Phone: (573) 751-2611
Visit
for additional information.
P.O. Box 300
TTY: (800) 735-2966
Jefferson City, MO 65105-0300
Fax: (573) 522-1720
E-mail:
excise@dor.mo.gov
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