Form Wv/mft-509ag-Sf - Motor Fuel Excise Tax Off-Highway Refund Application - Agriculture Special Fuel - 2007

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WV/MFT-509AG-SF
REV 1/07
WEST VIRGINIA STATE TAX DEPARTMENT
DEPARTMENT USE ONLY
INTERNAL AUDITING DIVISION
Postmark Date:
PO BOX 2991
CHARLESTON, WV 25330-2991
MOTOR FUEL EXCISE TAX
OFF-HIGHWAY REFUND APPLICATION - AGRICULTURE
SPECIAL FUEL
(TWELVE-MONTH ELIGIBILITY)
PLEASE PRINT OR TYPE
WV Identification Number:
Contact Person:
Name:
Telephone:
Ext:
DBA:
NOTE: This refund application is available for special fuel purchased in
Address:
quantities of twenty-five (25) gallons or more for use as a motor fuel in
internal combustion engines not operated upon the highways of this state
City:
for agricultural purposes.
State:
Zip:
PURPOSE FOR WHICH FUEL WAS CONSUMED: Give full details:
PLEASE READ INSTRUCTION ON BACK CAREFULLY
GALLONS
OFFICE USE ONLY
Incomplete applications will be returned.
Bulk Storage Capacity:
(If applicable)
A.
Opening Inventory Gallons
(Must agree with closing inventory on last application)
________________
B.
Total Gallons Purchased
(Gallons)
C.
Total Gallons
(Line A plus Line B)
D.
Closing Inventory Gallons
E.
Accountable Gallons
(Line C minus Line D)
F.
Gallons Used On Highway
Location
:
Fuel Was Consumed
G.
Gallons Sold
__________________
__________________
H.
GALLONS CLAIMED FOR REFUND (Line E minus F & G)
__________________
REFUND DUE
(Line H x $0.205)
.
$
$
I
(Variable Rate is Not Refundable for Off-Highway Use)
CAUTION: Please read this application before signing. Presenting a fraudulent application constitutes a felony.
I certify that, to the best of my knowledge, this application is accurate and complete.
SIGNATURE: ______________________________________TITLE: ________________________________DATE: _________________
DEPARTMENT USE ONLY
APPLICATION MUST BE NOTARIZED
Sworn to and subscribed before me this ______day of ________________20_____
AMOUNT OF REFUND $____________________
Seal of officer Taking Affidavit __________________________________________
NOTARY PUBLIC
APPROVED BY: __________________________
County of ____________________________State of________________________
DATE: ___________________________________
My Commission expires on the ___________day of __________________20_____
SERIAL NUMBER:
__________________________________________________________________
SIGNATURE OF PREPARER IF OTHER THAN APPLICANT

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