Form Wv/mft-509v Gas - Motor Fuel Excise Tax Government Refund Application - 2003
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1
2WEST VIRGINIA STATE TAX DEPARTMENT
WV/MFT-509V GAS
DEPARTMENT USE ONLY
INTERNAL AUDITING DIVISION
Org. 11/03
:
POSTMARK DATE
PO BOX 2991
CHARLESTON, WV 25330-2991
___________________
_
(304) 558-8500
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: USE FORM: WV/MFT-509V-STATE GAS)
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
plus
C. Total Gallons (Line A
Line B)
D. Closing Inventory
E.
Gallons Sold
minus
F.
Total Accountable Gallons (Line C
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
AMOUNT OF REFUND: $ _____________________________
Sworn to and subscribed before me this _________day ________________
GASOLINE GALLONS: _______________________________
Seal of Officer
Taking
Affidavit______________________________________________________
APPROVED BY: ______________________________________
NOTARY PUBLIC
SERIAL NUMBER:
County of ________________________State _______________________
My Commission expires on the _______day of ____________20________
WV State Code §11-14C
____________________________________________________________
SIGNATURE OF PREPARER IF OTHER THAN APPLICANT
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