Form Mf-001w - Taxicab Claim For Fuel Tax Refund Page 3

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Page 3
Fuel Purchase Schedule
This page may be reproduced if additional schedules are needed.
Invoice
Purchase
Fuel Type
Price Per
Gallons
Name and Address of Supplier
Number
Date
(e.g., gas, CNG)
Gallon
Purchased
Wisconsin Department of Revenue
R611

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