Form Mf-023w - Nonagricultural 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,
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FILE THIS CLAIM WITH:
NONAGRICULTURAL USERS - OFF-ROAD FUEL TAX REFUND CLAIM
Wisconsin Department of Revenue
MS 5-107
Instructions
PO Box 8900
FILING REMINDERS...
Madison, WI 53708-8900
• Claims must be filed within one year from the date fuel is purchased.
(608) 266-7363 or 266-6701
• Provide all information requested to avoid delays in processing your claim.
• No refund will be issued on less than 100 gallons.
Check this box if there has
been a recent change to your
name, address or ownership
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
29.1
per gallon
April 1, 2004 through March 31, 2005
¢
April 1, 2005 through March 31, 2006
29.9
¢
per gallon
ATTACH TO
(1) Invoices verifying fuel purchases and indicating 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:
that the fuel is exempt from the Wisconsin fuel tax.
Gasoline
Undyed Diesel
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 in each column 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 List in which motor vehicle fuel was used for off-road purposes (attach additional sheets, if necessary)
Column A
Column D
Column F
Column B
Column C
Column E
Activity Type
Refund
Equipment Type/
Fuel
Gallons
Allowable Percent
(see instructions)
Used
Gallons
Manufacturer Name
Type
(see instructions)
TOTAL GALLONS: must agree with total gallons you enter on line 6
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.
Signature (do not print or type)
Date
Business Telephone No.
(
)
MF-023W (R. 3-05)

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