Form Wv/mft-504 F - Supplier/permissive Supplier Schedule Of Disbursements

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WV/MFT-504 F
SUPPLIER/PERMISSIVE SUPPLIER SCHEDULE OF DISBURSEMENTS
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 5G
Exempt motor fuel sold for taxable purpose to
Licensed Distributors and Licensed Importers
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)
Mode
Point of
Date
Bill of Lading
Gross Gallons
Net Gallons
Carrier/l
Carrier/
Purchaser
INVOICED
Purchaser
Transporter
Transporter
Origin
Destination
Name
Loaded
Number
GALLONS
FEIN
Name
FEIN
TOTAL THIS PAGE
IMPORTANT NOTICE:
TOTAL ALL PAGES INVOICED GALLONS ONLY
You must obtain prior approval to submit your own schedules.
BY PRODUCT TYPE - TRANSFER TO LINE 4 OF WORKSHEET A

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