Form Wv/mft-504 A - Supplier/permissive Supplier Schedule Of Tax-Paid Receipts - 2004
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1WV/MFT-504 A
SUPPLIER/PERMISSIVE SUPPLIER SCHEDULE OF TAX-PAID RECEIPTS
REV 11/04
WEST VIRGINIA STATE TAX DEPARTMENT
INTERNAL AUDITING DIVISION
S
P O BOX 2991
Charleston, WV 25330-2991
(304) 558-8623; (304) 558-8624; (304) 558-8625; (304) 558-8626; (304) 558-8627
YOU MUST COMPLETE SEPARATE SCHEDULES FOR EACH PRODUCT TYPE AND SELLER
FEIN
NAME
MONTH/YEAR
SCHEDULE 1
TAX - PAID RECEIPTS
PRODUCT INFORMATION (CHECK APPLICABLE BOX)
MODE OF TRANSPORTATION CODES
□ 150 – #1 Fuel Oil
□ 228 – Diesel – Dyed
□ 054 – Propane
J – Truck
□ 125 – Aviation Gasoline
□ 160 – Diesel – Undyed
□ 224 – Compressed Natural Gas
R – Rail
□ 130 – Aviation Jet Fuel
□ 284 – Biodiesel – Undyed
□ 225 – Liquefied Natural Gas
B – Barge
□ 122 – Blending Components
□ 072 – Kerosene – Dyed
□ Other – Product Type ___________
□ 124 – Gasohol
□ 142 – Kerosene – Undyed
ST – Stationary Transfer
Product Code __________
□ 065 – Gasoline
BA – Book Adjustment
PRODUCT RECEIPT INFORMATION
(1)
(2)
(3)
(4)
(5)
(7)
(8)
(9)
(10)
(11)
(6)
Carrier/
Carrier/
Mode
Point of
Date
Bill of Lading
Gross Gallons
Net Gallons
Seller Name
INVOICED
Seller FEIN
Transporter Name
Transporter FEIN
Received
Number
Origin
Destination
GALLONS
TOTAL THIS PAGE
IMPORTANT NOTICE:
You must obtain prior approval to submit your own schedules.
TOTAL ALL PAGES INVOICED GALLONS ONLY
BY PRODUCT TYPE - TRANSFER TO LINE 12 OF WORKSHEET A
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