Form Mf-003w - Agricultural Users - Off-Road Fuel Tax Refund Claim

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FYI - click in Section A: 'Legal Name' field OR check address change box if applicable
Print
Clear
and tab through. Use mouse to check applicable boxes, spacebar, or Enter.
FILE THIS CLAIM WITH:
AGRICULTURAL USERS - OFF-ROAD FUEL TAX REFUND CLAIM
Wisconsin Department of Revenue
MS 5-107
Instructions
Post Office Box 8900
FILING REMINDERS...
Madison, WI 53708-8900
• Claims must be filed within one year from the date fuel is purchased.
Have questions? Contact us at:
• Provide all information requested to avoid delays in processing your claim.
(608) 266-7363 or 266-6701
• No refund will be issued on less than 100 gallons.
FAX (608) 261-7049
Check this box if there has been a recent change to your name, address or ownership
E-mail: excise@dor.state.wi.us
Please print or type
Social Security No. (if you are a
Federal Employer ID No.
AND/OR
Section A:
Legal Name
sole proprietor)
(FEIN)
Mailing Address – Street or PO Box Number
City
State
Zip Code
Type of Organization (check one)
Date of Incorporation or Registration:
Wisconsin County of Business
Location
3.
Wisconsin corporation
1.
Individual
LLC - Taxed as partnership
4.
Out-of-state corporation
2.
Partnership
LLC - Taxed as corporation
5.
Other: describe
LLC - Single member LLC only
Section B:
CAUTION
If fuel purchases cover more
DATES OF FUEL PURCHASES COVERED BY THIS REFUND CLAIM
than one fuel tax rate period,
Date of last
Date of first
you must submit a separate
Purchase
Purchase
refund claim for each period.
MOTOR VEHICLE FUEL TAX RATES
USE A SEPARATE CLAIM FORM
Period Covered by Your Purchases
Fuel Tax Rate
FOR EACH FUEL TAX RATE PERIOD
April 1, 2004 through March 31, 2005
29.1
per gallon
¢
April 1, 2005 through March 31, 2006
29.9
¢
per gallon
ATTACH TO
(1) Invoices verifying fuel purchases and indicting the amount of Wisconsin fuel tax paid.
YOUR CLAIM
(2) Adding maching tapes showing how you calculated the gallon totals entered on line 1 below.
Section C:
REFUND COMPUTATION SCHEDULE
**ENTER WHOLE GALLONS ONLY**
Invoice Caution: Do not include fuel purchases when the invoice states
FUEL TYPES:
Gasoline
Undyed Diesel
that the fuel is exempt from the Wisconsin fuel tax.
1. Total gallons purchased and used by fuel type (do not include tax-exempt purchases of fuel
or dyed diesel fuel)
2. Gallons included on line 1 used in licensed cars and trucks by fuel type
3. Gallons on which refund is claimed by fuel type (line 1 less line 2)
4. Motor vehicle fuel tax rate (enter one rate from schedule above)
5. Compute Refund (multiply gallons on line 3 in each column by the fuel tax rate entered on
line 4.) Enter total refund on line 7/8
6. TOTAL GALLONS FROM LINE 3
7. & 8. TOTAL REFUND CLAIMED
Add all columns on line 3
Add all columns on line 5 $
Section D:
Equipment in which motor vehicle fuel was used for off-road purposes (check all boxes that apply).
Combines
Bobcats
Skid Loaders
Tractors
Haybines
Other (please describe):
CAUTION: FUEL TAX IS NOT REFUNDABLE ON FUEL PLACED INTO LICENSED MOTOR VEHICLES even if the licensed vehicles
are used to perform farming activities like picking up supplies in town or checking on animals or crops in the fields.
HOW YOU CAN AVOID FILING REFUND CLAIMS ON FUEL PLACED INTO OFF-ROAD FARM EQUIPMENT
Dyed diesel fuel may be purchased tax-exempt but it cannot be placed in licensed motor vehicles or mixed with undyed diesel fuel.
Gasoline can be purchased tax-exempt in amounts of 100 gallons or more if delivered by your supplier. You must execute an
exemption certificate (MF-209) with your supplier to purchase gasoline tax-exempt for off-road use.
I declare that I have examined this claim and attachments and to the best of my knowledge and belief, it is true, correct and complete. The
motor vehicle fuel purchases on which this claim is based have been made within the last 12 months.
Date
Signature (do not print or type)
Business Telephone No.
(
)
MF-003W (R. 3-05)

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