Form Wv/mft-509v Sf - Motor Fuel Excise Tax Government Refund Application - West Virginia State Tax Department - 2003
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1
2WEST VIRGINIA STATE TAX DEPARTMENT
WV/MFT-509V SF
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
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
(STATE of WV and its Institutions: USE FORM: WV/MFT-509V-STATE SF)
PLEASE PRINT OR TYPE
WV Identification Number:
Contact Person:
Name:
Telephone:
Ext:
DBA:
PURPOSE OF FUEL CONSUMPTION: Brief Description
Address:
City:
State:
Zip:
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 - Original Receipts Only
plus
C. Total Gallons (Line A
Line B)
D. Closing Inventory
E. Gallons Sold
minus
F. Accountable Gallons (Line C
Line D and Line E)
G
GALLONS CLAIMED FOR REFUND
.
H. Refund Due / Flat and Variable Rate
(Line G X .2535)
$
I.
Refund Due /
(Line G X .0485)
$
Variable Rate Only
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:
DEPARTMENT USE ONLY
APPLICATION MUST BE NOTARIZED
AMOUNT OF REFUND: $_________________________
Sworn to and subscribed before me this _________day ________________
Seal of Officer
UNDYED (.2535) GALLONS: _____________________
Taking
DYED (.0485) GALLONS: ________________________
Affidavit______________________________________________________
NOTARY PUBLIC
County of ______________________State _________________________
APPROVED BY: ________________________________
My Commission expires on the _______day of ____________20________
SERIAL NUMBER
: ____________________________
____________________________________________________________
SIGNATURE OF PREPARER IF OTHER THAN APPLICANT
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