Form Wv/mft-507 - Motor Fuel Transporter Report - 2003 Page 2
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2WEST VIRGINIA STATE TAX DEPARTMENT
MOTOR FUEL TRANSPORTER REPORT
FILING INFORMATION
Provide all information requested on this report and attach all required schedules. Schedule 1 – Loaded in West Virginia and delivered to another state.
Schedule 2 – Loaded in another state and delivered in West Virginia.
Schedule 3 – Loaded in West Virginia and delivered in West Virginia.
Your return must be postmarked by the Last Day of the month following the report month.
INSTRUCTIONS
REPORT INFORMATION
Report Month, Day and Year
Enter the month, day and year you are reporting.
Due Date
Enter the month, day and year the report is due.
TRANSPORTER INFORMATION
FEIN/SSN
Enter the company’s Federal Employment Identification Number (FEIN) or
Social Security Number (SSN).
Name
Enter the Name of the Transporter.
Mailing Address, City, State, and Zip Code
Enter the Mailing Address, City, State, And Zip Code.
Telephone Number
Enter the Telephone Number.
Fax Number
Enter the Fax Number.
E-mail Address
Enter the E-Mail Address, if applicable.
PRODUCT LOAD INFORMATION
(1) “Product Loaded in West Virginia…”
Enter the total number of product gallons loaded at a terminal or bulk plant in West Virginia and
delivered into another state.
(2) “Product Loaded in Another State …”
Enter the total number of product gallons loaded at a terminal or bulk plant in another state and
delivered into West Virginia.
(3) “Product Loaded in West Virginia…”
Enter the total number of product gallons loaded at a terminal or bulk plant in West Virginia and
delivered into West Virginia.
(4) “Total Gallons Motor Fuel Transported”
Enter the total of Lines 1, 2 and 3.
CERTIFICATION
Authorized Representative’s Name, Title
Print or type the name and title of the person authorized by the Licensee to sign this report.
Authorized Representative’s Signature
Signature of Authorized Representative.
Date
Enter the date report was signed by Authorized Representative.
Telephone Number
Enter the Authorized Representative’s telephone number.
Fax Number
Enter the Authorized Representative’s fax number.
E-mail Address
Enter the Authorized Representative’s e-mail address.
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