Form Wv/gas-509v 11/03-Motor Fuel Excise Tax Government Refund Application

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WEST VIRGINIA DEPARTMENT OF TAX & REVENUE
WV/GAS-509V
DEPARTMENT USE ONLY
INTERNAL AUDITING DIVISION
:
Org. 11/03
POSTMARK DATE
PO BOX 2991
CHARLESTON, WV 25330-2991
___________________
_
MOTOR FUEL EXCISE TAX
GOVERNMENT REFUND APPLICATION
GASOLINE
United States Agencies, County Government Agencies, Municipal Governments, County Boards of Education, Urban Mass
Transportation Authorities, Bona Fide Volunteer Fire Departments, Nonprofit Ambulance Service or Emergency Rescue
Services and Civil Defense or Emergency Service Programs
(STATE of WV and its Institutions: US E FORM: WV/GAS-509V-State)
PLEASE PRINT OR TYPE
WV Identification Number:
Contact Person:
Name:
Telephone:
Ext:
DBA:
PURPOSE OF FUEL CONSUMPTION: Brief Description
Address:
City:
State:
Zip:
PLEASE READ INSTRUCTIONS ON BACK CAREFULLY
GASOLINE GALLONS
OFFICE USE
Incomplete forms will be returned and will cause a delay in your refund.
A. Opening Inventory Gallons
B. Total Gallons Purchased - Original Receipts Only
C. Total Gallons (Line A plus Line B)
D. Closing Inventory
E.
Gallons Sold
F. Total Accountable Gallons (Line C minus Line D and Line E)
G.
GALLONS CLAIMED FOR REFUND
H .
TOTAL REFUND DUE
$
$
(Line G x .2535)
.
CAUTION: Please read this application before signing. Presenting a fraudulent application constitutes a felony
I certify that, to the best of my knowledge, this application is accurate and complete.
_____________________________
_______________________________
__________________
SIGNATURE:
TITLE:
DATE:
APPLICATION MUST BE NOTARIZED
DEPARTMENT USE ONLY
Sworn to and subscribed before me this _________day ________________
AMOUNT OF REFUND: $ _____________________________
Seal of Officer
GASOLINE GALLONS: _______________________________
Taking
Affidavit______________________________________________________
NOTARY PUBLIC
APROVED BY: ______________________________________
County of ________________________State _______________________
My Commission expires on the _______day of ____________20________
SERIAL NUMBER:
____________________________________________________________
SIGNATURE OF PREPARER IF OTHER THAN APPLICANT

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