Form Wv/mft-509pto-Gas - Motor Fuel Excise Tax Refund Application - 2005

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WEST VIRGINIA STATE TAX DEPARTMENT
DEPARTMENT USE ONLY
Postmark Date:
WV/MFT-509PTO-GAS
INTERNAL AUDITING DIVISION
REV 5/05
PO BOX 2991
CHARLESTON, WV 25330-2991
MOTOR FUEL EXCISE TAX
REFUND APPLICATION – POWER TAKE OFF (PTO)
GASOLINE
Please select the quarter for which you are applying:
Purchases (Receipts) Dated
Due Date
⃞
March 31
January 1 – March 31
April 30
⃞
June 30
April 1 – June 30
July 31
⃞
September 30
July 1 – September 30
October 31
⃞
December 31
October – December 31
January 31
PLEASE PRINT OR TYPE
WV Identification Number:
Contact Person:
Name:
Telephone:
Ext:
DBA:
NOTE
:
Refund application is available to cement mixer trucks and
Address:
garbage trucks only, when the vehicle with auxiliary equipment uses
GASOLINE and there is no auxiliary motor for the equipment or separate
City:
tank for a motor.
State:
Zip:
Indicate type of PTO Unit
⃞ Cement Mixer Truck
⃞ Garbage Truck
⃞ Check if also filing off-highway application
PLEASE READ INSTRUCTIONS ON BACK CAREFULLY
GALLONS
OFFICE USE ONLY
Incomplete applications will be returned will cause a delay or denial of your refund.
A.
Opening Inventory Gallons
(Must agree with closing inventory on last application)
B.
Total Gallons Purchased
C.
Total Gallons
(Line A plus Line B)
D.
Closing Inventory Gallons
(Use as opening inventory on next application)
E.
Accountable Gallons
(Line C minus Line D)
F.
GALLONS USED ON HIGHWAY
G.
PTO GALLONS CLAIMED FOR REFUND
H
.
REFUND DUE
$
$
(Line G x $.205 X 25%)
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
Sworn to and subscribed before me this ______day of ________________20_____
AMOUNT OF REFUND $____________________
Seal of officer Taking Affidavit __________________________________________
NOTARY PUBLIC
APPROVED BY: __________________________
County of ____________________________State of________________________
DATE: ___________________________________
My Commission expires on the ___________day of __________________20_____
SERIAL NUMBER:
__________________________________________________________________
SIGNATURE OF PREPARER IF OTHER THAN APPLICANT

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