Form Wv/mft-504 G - Supplier/permissive Supplier Schedule Of Disbursements
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1SUPPLIER/PERMISSIVE SUPPLIER SCHEDULE OF DISBURSEMENTS
WV/MFT-504 G
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 PURCHASER
FEIN
NAME
MONTH/YEAR
SCHEDULE 5H
Exempt motor fuel sold for a taxable purpose to
Unlicensed Distributors, and Licensed Suppliers
PRODUCT INFORMATION (CHECK APPLICABLE BOX)
MODE OF TRANSPORTATION
□ 125 – Aviation Gasoline
□ 054 – Propane
J – Truck
ST – Stationary Transfer
□ 130 – Aviation Jet Fuel
□ Other – Product Type ___________
R – Rail
BA – Book Adjustment
Product Code __________
B – Barge
PRODUCT DISBURSEMENT INFORMATION
(1)
(2)
(3)
(4)
(5)
(7)
(8)
(9)
(10)
(11)
(6)
Carrier/
Carrier/
Mode
Point of
Purchaser
Date
Bill of Lading
Gross Gallons
Net Gallons
Purchaser
INVOICED
Loaded
Number
Transporter
Transporter
Origin
Destination
Name
FEIN
GALLONS
Name
FEIN
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 2 OF WORKSHEET A
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Parent category: Financial