Form Wv/mft-507 - Motor Fuel Transporter Report - 2003
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2WV/MFT-507
Org. (5/03)
C
WEST VIRGINIA STATE TAX DEPARTMENT
INTERNAL AUDITING DIVISION
PO BOX 2991
CHARLESTON, WV 25330-2991
(304) 558-8500
MOTOR FUEL TRANSPORTER REPORT
WV CODE §11-14C-40 IMPOSES A $50 PENALTY FOR THE LATE FILING OF THIS REPORT
You must keep a copy of this report for your records.
(CHECK APPLICABLE BOXES)
□ Address has changed since prior report
□ Amended report
□ Final report for closed business
Please Print in Ink or Type
REPORT INFORMATION
Period Ending (Month, Day and Year)
Due Date (Month, Day and Year)
TRANSPORTER INFORMATION
FEIN/SSN
Name
Mailing Address
City
State
Zip Code
Telephone Number
Fax Number
E-mail Address
(
)
(
)
PRODUCT LOAD INFORMATION
GROSS GALLONS
NET GALLONS
LINE
DESCRIPTION
1
Product loaded in West Virginia at a Terminal or Bulk Plant and delivered to another
state (Schedule 1).
2
Product loaded in another state at a Terminal or Bulk Plant and delivered into West
Virginia (Schedule 2).
3
Product loaded in West Virginia and delivered into West Virginia (Schedule 3).
4
TOTAL GALLONS OF MOTOR FUEL TRANSPORTED.
(Add Lines 1, 2, and 3).
CERTIFICATION
I certify that I have read this report and all supporting documents and know their contents and that all information on both the report and supporting documents are
true, accurate, and complete.
Authorized Representative’s Name (Please Print)
Title
Authorized Representative’s Signature
Date
Telephone Number
Fax Number
E-mail Address
(
)
(
)
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