Form 574 - Distributor'S Schedule Of Receipts Page 2
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2This 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
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 01-2016)
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