Form Vmft-501 - Distributor Report Po Box 2991 Charleston, Wv 25330-2991 - West Virginia Motor Fuel
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1
2WEST VIRGINIA MOTOR FUEL DISTRIBUTOR REPORT
*O05110301W*
WV/MFT-501
PO BOX 2991
REV 12-06
CHARLESTON, WV 25330-2991
(304) 558-8623; (304) 558-8624; (304) 558-8625; (304) 558-8626; (304) 558-8627
D
Please Print or Type
Y
ou must keep a copy of this report for your records
DISTRIBUTOR INFORMATION
Period Ending (Month, Day and Year)
FEIN
NAME
)
Mailing Address
City
State
Zip Code
Due Date (Month, Day and Year
Telephone Number
Fax Number
E-mail Address
(
)
(
)
TAX CALCULATION
Dyed Diesel &
Aviation
Aviation
Clear
USE INVOICED GALLONS
Gasoline
Gasohol
Undyed Diesel
Propane
Dyed Kerosene
Gasoline
Jet Fuel
Kerosene/Other
Gallons @ .11
Gallons @ .11
Gallons @ .11
Gallons @ .11
.
Total Gallons Tax Unpaid
1
(Schedule 2)
Flat Rate Tax Due
2.
$
$
$
$
(Line 1 multiplied by $0.2050)
Variable Rate Due
3.
$
$
$
$
$
$
$
$
(Line 1 multiplied by $0.11)
Gallons @.2050
Gallons @.2050
Gallons @.2050
4. Fuel exempt from flat rate sold for
taxable use (Schedule 5X)
Tax Due
5.
– Fuel exempt from flat
$
$
$
rate sold for taxable use
(Line 4 multiplied by $.2050)
TAX DUE
6.
$
$
$
$
$
$
$
$
(Add Lines 2, 3 and 5)
TOTAL TAX DUE
7.
$
(Add line 6 all columns and enter total)
CERTIFICATION : I certify that I have read this report and all supporting documents and know their contents and that all information on both the report and supporting documents are true,
accurate, and complete.
Authorized Representative’s Name
Authorized Representative’s Signature
Date
(Please Print)
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