Form 574 - Distributor'S Schedule Of Receipts
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MISSOURI DEPARTMENT OF REVENUE
FORM
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TAXATION DIVISION
574
P.O. BOX 300, JEFFERSON CITY, MISSOURI 65105-0300
(573) 751-2611
TDD (800) 735-2966
PAGE
(REV. 02-2011)
DISTRIBUTOR’S SCHEDULE OF RECEIPTS
OF
SEE INSTRUCTIONS ON REVERSE SIDE
DISTRIBUTOR’S NAME
LICENSE NUMBER
FEIN
SCHEDULE TYPE
MONTH, YEAR
__ __ __ __ __ __ __ __ __
__ __ / __ __ __ __
SCHEDULE TYPE
PRODUCT TYPE — Complete a separate schedule for each product type
1.
Gallons received in Missouri tax and/or fees paid
CIRCLE ONE
1B. Gallons received for export, destination state tax, and/or fees paid
065 — Gasoline
160 — Clear Diesel Fuel
1C. Gallons received tax and/or fees paid with an import payment voucher
072 — Dyed Kerosene
228 — Dyed Diesel Fuel
1E. Gallons imported from another state, Missouri tax, and/or fees paid
123 — Alcohol
284 — Bio-Diesel – Undyed B100
2A. Gallons received tax and/or fees unpaid—provide explanation below. (e.g., tank wagon imports and/or untaxed
241 — Ethanol
285 — Soy Oil
alcohol or Bio-Diesel — Undyed B100)
124 — Gasohol
290 — Bio-Diesel – Dyed B100
2B. Gallons of blend stock received tax and/or fees unpaid.
125 — Aviation Gasoline
122 — Blending Components
2G. Gallons of clear kerosene received fees paid (for sale through barricaded pumps)
130 — Jet Fuel
(Identify)
142 — Clear Kerosene
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POINT OF
NAME OF CARRIER
CARRIER’S
MODE
SELLER’S NAME
SELLER’S
DATE
DOCUMENT
NET
GROSS
INVOICED
FEIN
ORIGIN
DEST.
FEIN
RECEIVED
NUMBER
GALLONS
GALLONS
GALLONS
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PAGE TOTAL
SCHEDULE TOTAL
EXPLANATION
This form is available upon request in alternative accessible format(s).
MO 860-1111 (02-2011)
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Parent category: Financial