Form Wv/mft-504f - Supplier/permissive Supplier Schedule Of Disbursements - 2003
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1
2WEST VIRGINIA STATE TAX DEPARTMENT
WV/MFT-504 F
Org. (5/03)
INTERNAL AUDITING DIVISION
P O BOX 2991
Charleston, WV 25330-2991
(304) 558-8500
SUPPLIER/PERMISSIVE SUPPLIER SCHEDULE OF DISBURSEMENTS
FEIN/SSN
NAME
SCHEDULE NUMBER – 5G
MONTH/YEAR
Exempt motor fuel sold for taxable
purpose to licensed distributors and
licensed importers
PRODUCT INFORMATION (CHECK APPLICABLE BOX)
MODE OF TRANSPORTATION CODES
(COMPLETE SEPARATE SCHEDULES FOR EACH PRODUCT TYPE YOU DELIVER)
□ 125 – Aviation Gasoline
□ 054 – Propane
J – Truck
ST – Stationary Transfer
□ 130 – Aviation Jet Fuel
□ Other – Product Type ___________
R – Rail
BA – Book Adjustment
Product Code __________
B – Barge
PRODUCT DISBURSEMENT INFORMATION
(1)
(2)
(3)
(4)
(5)
(7)
(8)
(9)
(10)
(11)
(6)
Carrier’s/Motor
Carrier’s/Motor
Mode
Point of
Purchaser’s
Date
Document
Gross Gallons
Net Gallons
INVOICED
Purchaser’s
Origin
Destination
Shipped
Number
GALLONS
Fuel
Fuel
Name
FEIN/SSN
Transporter’s
Transporter’s
Name
FEIN/SSN
Sub Total
GRAND TOTAL OF INVOICED GALLONS – Transfer to Line 4 of Worksheet A
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