Form Wv/mft- 509 Gas - Motor Fuel Excise Tax Off-Highway Refund Application Gasoline - 2003

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WV/MFT- 509 GAS
Org. 11/03
WEST VIRGINIA STATE TAX DEPARTMENT
INTERNAL AUDITING DIVISION
PO BOX 2991
DEPARTMENTAL USE ONLY
Postmark Date:
CHARLESTON, WV 25330-2991
(304) 558-8500
MOTOR FUEL EXCISE TAX
OFF-HIGHWAY REFUND APPLICATION
GASOLINE
(SIX-MONTH ELIGIBILITY)
PLEASE PRINT OR TYPE
WV Identification Number:
Contact Person:
Name:
Telephone:
Ext:
DBA:
NOTE: This refund application is available for gasoline purchased in
Address:
quantities of twenty-five (25) gallons or more for use as a motor fuel in
internal combustion engines not operated upon the highways of this
City:
state.
State:
Zip:
PURPOSE FOR WHICH FUEL WAS CONSUMED: Give full details:
PLEASE READ INSTRUCTION ON BACK CAREFULLY
GALLONS
OFFICE USE ONLY
Bulk Storage Capacity:
Incomplete applications will be returned.
(If applicable)
A.
Opening Inventory Gallons
(Must agree with closing inventory on last application)
________________
B.
Total Gallons Purchased (Original Receipts Only)
(Gallons)
C.
Total Gallons (Line A plus Line B)
D.
Closing Inventory Gallons
Accountable Gallons (Line C minus Line D)
E.
Location
F.
Gallons Used On Highway
Fuel Was Consumed
:
G.
Gallons Sold
__________________
__________________
H.
GALLONS CLAIMED FOR REFUND (Line E minus F & G)
__________________
(
REFUND DUE
Line H x $.205)
$
$
I
.
(Variable Rate $.0485 is Not Refundable for Off-Highway Use)
CAUTION: Please read this application before signing. Presenting a fraudulent application constitutes a felony.
I certify that, to the best of my knowledge, this application is accurate and complete.
SIGNATURE: ______________________________________TITLE: ________________________________DATE: _________________
APPLICATION MUST BE NOTARIZED
DEPARTMENTAL USE ONLY
Sworn to and subscribed before me this ______day of ________________20_____
AMOUNT OF REFUND $______________________
Seal of officer Taking Affidavit __________________________________________
NOTARY PUBLIC
GASOLINE GALLONS: ___________________
County of ____________________________State of________________________
My Commission expires on the ___________day of __________________20_____
APPROVED BY: _____________________________
__________________________________________________________________
DATE: ______________________________________
SIGNATURE OF PREPARER IF OTHER THAN APPLICANT
SERIAL NUMBER:

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