Form Wvmft-509b-Phc - Motor Fuel Excise Tax Refund Application For Sellers Of Propane To Poultry House Consumers
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1
2WEST VIRGINIA STATE TAX DEPARTMENT
WVMFT--509B-PHC
Org. 11/03
INTERNAL AUDITING DIVISION
DEPARTMENT USE ONLY
Postmark Date:
P.O. BOX 2991, CHARLESTON, WEST VIRGINIA 25330-2991
(304) 558-8500
MOTOR FUEL EXCISE TAX
Current Tax Rate
REFUND APPLICATION FOR SELLERS OF
$.0485
PROPANE TO POULTRY HOUSE CONSUMERS
PLEASE PROVIDE A NAME AND TELEPHONE NUMBER OF SOMEONE
AVAILABLE 8:30 A.M. – 4:30 P.M. TO DISCUSS THIS APPLICATION
FEIN/WV IDENTIFICATION NUMBER
NAME:
NAME
(
)
ADDRESS (CHECK WILL BE MAILED TO THIS ADDRESS)
TELEPHONE NUMBER INCLUDING AREA CODE
Refund Application Is Available To All Gallons Of Tax-Paid PROPANE sold to poultry house consumers
NOTE: IN ORDER TO RECEIVE REFUND, AN EXEMPTION CERTIFICATE MUST BE ON FILE
BUSINESS REGISTRATION CERTIFICATE
NUMBER OF POULTRY HOUSE HEATING
SOLD TO:
DATE
CONSUMER
GALLONS
(FROM EXEMPTION CERTIFICATE)
NAME
ADDRESS
SOLD
A.
GALLONS CLAIMED FOR REFUND
(Add all lines)
Computation of
Refund
B. TOTAL REFUND DUE
(Multiply Line A by .0485)
$
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
__________________
FOR DEPARTMENT USE ONLY
Sworn to and subscribed before me this ________day of ______________
20___.
$
AMOUNT OF REFUND
________________________
Seal of Officer Taking
Affidavit______________________________________________________
SPECIAL FUEL GALLONS: _____________________
NOTARY PUBLIC
APPROVED BY: ______________________________
County of ________________________State _______________________
DATE APPROVED: ____________________________
My Commission expires on the _______day of ____________20________
SERIAL NUMBER:
____________________________________________________________
SIGNATURE OF PREPARER IF OTHER THAN APPLICANT
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