Form Wv/mft-509b Home - Motor Fuel Excise Tax Refund Application For Consumers Of Clear Kerosene Used For Heating Of Public/private Dwellings

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WEST VIRGINIA DEPARTMENT OF TAX AND REVENUE
WV/MFT-509B HOME
Org. 11/03
INTERNAL AUDITING DIVISION
DEPARTMENT USE ONLY
P.O. BOX 2991, CHARLESTON, WEST VIRGINIA 25330-2991
Postmark Date:
(304) 558-8500
MOTOR FUEL EXCISE TAX
REFUND APPLICATION FOR CONSUMERS OF CLEAR
Current Tax Rate
KEROSENE USED FOR HEATING OF PUBLIC/PRIVATE DWELLINGS
$.205
Please provide a name and telephone number of someone
WV Identification Number/Social Security Number _______________________________
available, if necessary to discuss this application.
Name __________________________________________________________________
Name: _____________________________________________
Address _________________________________________________________________
Telephone: _________________________________________
________________________________________________________________________
A.
GALLONS CLAIMED FOR REFUND
Computation of
Refund
$
B. TOTAL REFUND DUE (
Line A by .205)
Multiply
EXAMPLE: 10 GALLONS OF TAX PAID KEROSENE X .205 = $2.05 REFUND
ENTER THE NAME AND ADDRESS OF THE RETAILER(S) FROM WHOM THE UNDYED KEROSENE WAS PURCHASED (ATTACH ADDITIONAL PAGES IF NEEDED)
NAME
ADDRESS
Caution
Read this application before signing. Presenting a fraudulent claim constitutes a felony.
:
I I certify that, to the best of my knowledge, this claim is accurate and complete.
SIGNATURE__________________________________________________TITLE__________________________________________DATE
__________________
WV State Code §11-14 C: State law provides for a refund of the Motor Fuel Excise Tax - Flat Rate ($.205) on all gallons of tax-paid clear
kerosene used and consumed in an off-highway purpose for heating of any public or private dwelling, building or other premises.
REFUND INFORMATION AND INSTRUCTIONS
IF YOU HAVE PURCHASED UNDYED KEROSENE FROM A RETAILER ON OR AFTER JANUARY 1, 2004 THAT HAS CHARGED
THE .205 PER GALLON, YOU MUST ENTER THE NAME AND ADDRESS OF THE RETAILER IN THE SPECIFIED SECTION.
Failure to comply with the instructions or failure to complete the application may result in the denial of the refund, a delay in payment,
or reduction in the refund amount requested.
The application must be filed within six (6) months of purchase and completed
accurately. Original receipts must be attached to this application. 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, Federal Identification Number or Social Security Number,
whichever is applicable.
Applicants Name and Address: Complete all requested information. Checks are issued in the applicants name as shown on this
application and will be mailed to the address listed as the mailing address.
Contact Person: Provide someone who can answer questions if necessary for the department to discuss the application.
Should you have any questions or need assistance, please call one of the following:
Carol Brown
Donald Butler
Donna Purdy
(304) 558-8626
(304) 558-8623
(304) 558-8625
cbrown@tax.state.wv.us
dbutler@tax.state.wv.us
dpurdy@tax.state.wv.us
Tonja Oakes, Unit Manager
(304) 558-8621
toakes@tax.state.wv.us
FOR DEPARTMENT USE ONLY
AMOUNT OF REFUND $___________________________
SPECIAL FUEL GALLONS: _____________________
APPROVED BY: __________________________________
DATE APPROVED:
__________________________
SERIAL NUMBER:

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