Form Wv/mft-504 D - Importer Schedule Of Diversions - 2004
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1IMPORTER SCHEDULE OF DIVERSIONS
INTO WEST VIRGINIA
WV/MFT-508 D
REV 11/04
WEST VIRGINIA STATE TAX DEPARTMENT
INTERNAL AUDITING DIVISION
P O BOX 2991
J
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 PURCHASER
FEIN
NAME
MONTH/YEAR
SCHEDULE
11
PRODUCT INFORMATION (CHECK APPLICABLE BOX)
MODE OF TRANSPORTATION
□ 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
Product Code __________
□ 065 – Gasoline
PRODUCT RECEIPT INFORMATION
(1)
(2)
(3)
(4)
(5)
(7)
(8)
(9)
(10)
(11)
(12)
(6)
Transporter
Transporter
Mode
Point of
Purchaser’s
Date
Bill of
Gross
Net
INVOICED
Diversion
Purchaser’s
Loaded
Lading
Gallons
Gallons
GALLONS
Number
Name
Origin
Destination
Name
FEIN/SSN
FEIN
Number
: YOU MUST OBTAIN PRIOR APPROVAL TO SUBMIT YOUR OWN
IMPORTANT NOTICE
TOTAL THIS PAGE
SCHEDULES
TOTAL ALL PAGES INVOICED GALLONS ONLY
BY PRODUCT TYPE - TRANSFER TO LINE 2 AND 4 OF REPORT
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