Form Wv/mft-509g-Sf - Motor Fuel Excise Tax Refund Application - 2007

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DEPARTMENT USE ONLY
Postmark Date:
WV/MFT-509G-SF
WEST VIRGINIA STATE TAX DEPARTMENT
REV 1/07
INTERNAL AUDITING DIVISION
PO BOX 2991
CHARLESTON, WV 25330-2991
STATE GOVERNMENT
USE FORM WV/MFT-509S-SF
MOTOR FUEL EXCISE TAX
REFUND APPLICATION –GOVERNMENT
SPECIAL FUEL
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
Refund application must be submitted no later than the thirty-first (31st) day of August for purchases of motor fuel
made during the preceding fiscal year ending the thirtieth (30th) day of June.
PLEASE PRINT OR TYPE
WV Identification Number:
Contact Person:
Name:
Telephone:
Ext:
DBA:
Address:
City:
State:
Zip:
PURPOSE FOR WHICH FUEL WAS CONSUMED: Give full details:
A
B
GALLONS
GALLONS
OFFICE USE
PLEASE READ INSTRUCTIONS ON BACK CAREFULLY
Incomplete forms will be returned and will cause a delay in your refund.
(UNDYED FUEL)
(DYED FUEL)
A. Opening Inventory Gallons
B. Total Gallons Purchased
C. Total Gallons
(Line A plus Line B)
D. Closing Inventory
E. Gallons Sold
F. Accountable Gallons
(Line C minus Line D and Line E)
G. GALLONS CLAIMED FOR REFUND
H. Refund Due - Flat and Variable Rate
$
(Line G X .315)
I.
Refund Due - Variable Rate Only
$
(Line G X .11)
J. TOTAL REFUND DUE
$
(Add Lines H and I)
.
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
GOVERNMENT
Sworn to and subscribed before me this ______day of ________________20_____
Seal of officer Taking Affidavit __________________________________________
NOTARY PUBLIC
AMOUNT OF REFUND $____________________
County of ____________________________State of________________________
APPROVED BY: __________________________
My Commission expires on the ___________day of __________________20_____
DATE: ___________________________________
__________________________________________________________________
SERIAL NUMBER:
SIGNATURE OF PREPARER IF OTHER THAN APPLICANT

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