Form Wv/mft-509 Gas - Motor Fuel Excise Tax Refund Application For Sales To Federal Government - 2007 Page 2
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2REFUND INFORMATION AND INSTRUCTIONS
Failure to comply with the instructions or failure to complete the application may result in the disallowance of the refund, a delay
in payment, or reduction in the refund amount requested.
The application must be completed timely and accurately. Any
application for a refund not timely filed is not construed to be or constitute a moral obligation of the State of West Virginia for
payment. Incomplete forms or late-filed applications will be returned.
WV Identification Number: Enter your West Virginia Identification Number. If you do not have a West Virginia Identification
Number, enter your Federal Employer Identification Number. If you do not have a West Virginia Identification Number or a
Federal Employer Identification Number, enter your Social Security Number.
Applicant Name and Address: Complete all requested information. Checks will be issued to the applicant at the address as
shown on this application.
Contact Person: Provide someone who can discuss the application if necessary.
FUEL ACCOUNTABILITY:
•
Attach original or duplicate original invoice. Certified copies of sales slips, invoices, billing statements, and electronic
invoices are acceptable in lieu of original invoices at the discretion of the Tax Commissioner. Invoices must provide
complete details of the purchase. Name and address of supplier, name and address of purchaser, date of purchase or
delivery, product purchased, number of gallons purchased and the price of product.
•
Invoices and copies of checks showing the amount paid by the Federal Government must be included to prove that the
tax was refused.
•
The affidavit at the bottom of this form must be completed.
•
The right to receive a refund is not assignable. No payment of the refund may be made to any person other than the
original person entitled.
•
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.
GENERAL INFORMATION: The information provided is to assist a person filing a refund application and to possibly avoid
delays in the processing of your application.
Should you have any questions, please contact one of the following:
Carol Brown
Donald Butler
(304) 558-8627
(304) 558-8623
cbrown@tax.state.wv.us
dbutler@tax.state.wv.us
Crystal Ellington
Donna Purdy
(304) 558-8626
(304) 558-8625
cellington@tax.state.wv.us
dpurdy@tax.state.wv.us
A F F I D A V I T
State of ___________________)
County of__________________)
____________________________ _______________________ of the __________________________________
Taxpayer ID Number
Title
Company Name
___________________________________ personally appeared before me and being duly sworn deposes and says
Address
that:: _______________________________________________________________________________________.
__________________________________________
Company
________________________________________________________________
Signature
________________________________________________________________
Title
Subscribed and sworn to before me this _______day of _________________,20____.
________________________________________________
Notary Public
Notary Seal:
My Commission expires: __________________________
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