Form Wv/mft-511 - West Virginia Exporter Report
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1
2CHECK APPLICABLE BOX (ES)
L
□ Address has changed since prior report
*O06110401W
WV/MFT-511
REV 12/06
WEST VIRGINIA EXPORTER REPORT
□ Amended report
PO BOX 2991 CHARLESTON, WV 25330-2991
□ Final Report for closed business
(304) 558-8623; (304) 558-8624; (304) 558-8625; (304) 558-8626; (304) 558-8627
You must file this report monthly even if no activity occurred during the month
You must keep a copy of this report for your records
Period Ending (Month, Day and Year)
FEIN
NAME
Due Date (Month, Day and Year)
Mailing Address
City
State
Zip Code
Contact Person (required)
Telephone
Fax Number
E-mail Address
(
)
(
)
Dyed Diesel &
Aviation
Aviation
Clear Kerosene /
REFUND CALCULATION
Gasoline
Gasohol
Undyed Diesel
Propane
Dyed Kerosene
Gasoline
Jet Fuel
Other
GALLONS EXPORTED
1.
(Schedule 7B)
West Virginia Tax Paid – FLAT RATE
GALLONS EXPORTED
(Schedule 7B)
2.
West Virginia Tax Paid-VARIABLE RATE
Diversions from WV –GALLONS
3.
FLAT RATE (Schedule 11A)
Diversions from WV –GALLONS
4.
VARIABLE RATE (Schedule 11A)
TOTAL GALLONS TO BE REFUNDED
5.
FLAT RATE (Add lines 1 and 3)
TOTAL GALLONS TO BE REFUNDED
6.
VARIABLE RATE (Add lines 2 and 4)
AMOUNT TO BE REFUNDED
7.
$
$
$
$
FLAT RATE (Multiply line 5 x .2050)
AMOUNT TO BE REFUNDED
8.
$
$
$
$
$
$
$
$
VARIABLE RATE (Multiply line 6 x .117)
REFUND DUE
9.
(Add lines 7 and 8)
$
$
$
$
$
$
$
$
$
TOTAL REFUND DUE
10.
Add all columns line 9)
(
$
LESS DISCOUNT
11.
Multiply line 10 x .0075)
(
$
GRAND TOTAL REFUND DUE
12.
Subtract line 11 from line 10)
(
TAX DUE CALCULATION
Gallons Diverted into West Virginia –
13.
Flat Rate (Schedule 11)
Gallons Diverted into West Virginia
14.
Variable Rate (Schedule 11)
15. TAX DUE – FLAT RATE
$
$
$
$
(
Multiply line 13 x .2050)
16. TAX DUE – VARIABLE RATE
$
$
$
$
$
$
$
$
(Multiply line 14 x .117)
TAX DUE
17.
(Add lines 15 and 16)
$
$
$
$
$
$
$
$
. TOTAL TAX DUE
$
18
(Add all columns line 17)
Total Amount of Refund Due
$
19.
IF LINE 12 IS GREATER - Subtract line 18 from line 12 –ENTER AMOUNT OF REFUND
CHECK ONE
_____REFUND ______ CREDIT
Total Amount of Tax Due
$
IF LINE 18 IS GREATER- Subtract line 12 from line 18 –ENTER AMOUNT OF TAX DUE CHECK ONE _____ACH CREDIT _____ACH DEBIT ______CHECK
20.
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 (Please Print
______________________________________Authorized Representative’s Signature _______________________________________
_______________
Date
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