Form Mf-023w - Nonagricultural Users - Off-Road Fuel Tax Refund Claim 2000
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1NONAGRICULTURAL USERS – OFF-ROAD FUEL TAX REFUND CLAIM
FILE THIS CLAIM WITH:
Wisconsin Department of Revenue
FILING REMINDERS...
Post Office Box 8900
Madison, WI 53708-8900
(608) 266-7363 or 266-6701
Check this box if there has been a recent
Please print or type
change to your name, address or ownership
1. Name of Claimant (one name only)
2.
Federal Employer ID No.
AND Social Security No.
(if you
(FEIN)
are a sole proprietor)
__ __ – __ __ __ __ __ __ __
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3. Mailing Address - Street or P. O. Box Number
4. City
5. State
6. Zip Code
7. Type of Activity (check one)
8. DATES OF FUEL PURCHASES COVERED BY THIS REFUND CLAIM
more than one year prior to filing this claim.
2
3
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Ready-Mix
Waste Management
Date of first
Date of last
4
7
Other
Urban Transit
purchase
_________________
purchase
__________________
9. Type of Organization (check one)
indicate date incorporated
10. Wis. County of Business
Location
____ Individual
____ Wisconsin corporation
___________
_____ Other: describe
____ Partnership
____ Out-of-state corporation ___________
_________________
ATTACH TO YOUR CLAIM:
(1) Invoices verifying fuel purchases and indicating the amount of Wisconsin fuel tax paid.
(2) Adding machine tapes showing how you calculated the gallon totals entered on line 12 below.
If your invoices cover this period:
Use this tax rate:
REFUND COMPUTATION SCHEDULE
April 1, 1999 – March 31, 2000
25.8¢ per gallon
Invoice Caution: Do not include fuel purchases when the invoice
April 1, 2000 – March 31, 2001
26.4¢ per gallon
states that the fuel is exempt from the Wisconsin fuel tax.
11. Motor vehicle fuel tax rates.
FUEL TAX RATE
FUEL TAX RATE
Indicate the rates that apply to the invoices you submit with
_______ . ____ ¢ per gallon
_______ . ____ ¢ per gallon
this claim. Enter the earlier rate in the left two columns.
Gasoline
Undyed Diesel
Gasoline
Undyed Diesel
FUEL TYPES
12. Total gallons purchased and used at each fuel rate (do not
include any tax-exempt purchases of fuel or dyed diesel fuel)
13. Gallons included on line 12 used in licensed cars and trucks
14. Gallons on which refund is claimed (line 12 less line 13)
15. Compute Refund (multiply gallons on line 14 in each column
by the fuel tax rate on line 11). Enter total refund on line 16b.
16a. TOTAL GALLONS FROM LINE 14
16b. TOTAL REFUND CLAIMED
(enter whole gallons only)
Add all columns on line 14
____________________________
Add all columns on line 15
$ ________________________
17. List equipment in which motor vehicle fuel was used for off-road purposes (attach additional sheets or computer printouts)
Col. A
Col. B
Col. C
Col. D
Ready-mix, waste management, and liquid waste
Type of
Manufacturer’s
Gallons Used in Each
companies that have trucks with power take-off units must
Equipment
Name
During Claim Period
complete this column (see instructions for lines 13 & 17)
POWER TAKE-OFF UNITS
Power Take-off Gallons
Ready-mix trucks:
Enter 35% of col. C gallons
>>
Waste management trucks:
Enter 30% of col. C gallons
>>
Liquid waste pumping trucks:
Enter 15% of col. C gallons
>>
Other Equipment Gallons
OTHER EQUIPMENT YOU USED
FOR OFF-ROAD PURPOSES
Enter 100% of col. C gallons
>>
TOTAL GALLONS
TOTAL GALLONS
Must agree with total gallons you enter on
Must agree with total gallons
ine 16a (unless you complete column D) ...
you enter on line 16a
l
.................
DECLARATION: I declare that I have examined this claim and attachments and to the best of my knowledge and belief it is true,
correct and complete. The motor vehicle fuel purchases on which this claim is based have been made within the last 12 months.
Signature (do not print or type)
Business Telephone No.
Date
(
)
MF-023W (R. 2-00)
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