Form Mf-003w - Agricultural Users Off-Road Fuel Tax Refund Claim
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1
2A
U
FILE THIS CLAIM WITH:
GRICULTURAL
SERS
Wisconsin Department of Revenue
O
R
F
T
R
C
FF-
OAD
UEL
AX
EFUND
LAIM
Post Office Box 8900
Madison, WI 53708-8900
FILING REMINDERS...
Have questions? Contact us at:
(608) 266-7363 or 266-6701
FAX (608) 261-7049
E-mail: excise@dor.state.wi.us
Check this box if there has been a recent
change to your name, address or ownership
Please print or type
1. Name of Claimant (one name only please)
2. Federal Employer ID No.
Social Security No.
AND
(if you
(FEIN)
are a sole proprietor)
__ __ – __ __ __ __ __ __ __
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3. Mailing Address - Street or P. O. Box Number
4. City
5. State
6. Zip Code
7. DATES OF FUEL PURCHASES COVERED BY THIS CLAIM
8. FARM ACREAGE
ore you file this claim.
Date of first
Date of last
Total tillable
purchase
_______________
purchase
_________________
acres of farm
___________________
9. Type of Organization (check one)
10. Wisconsin County of
indicate date incorporated
Business Location
____ Individual
____ Wisconsin corporation
_______________
____ Partnership
____ Out-of-state corporation _______________
____ Other: describe ____________________________________
____________________
ATTACH TO YOUR CLAIM:
(1) Invoices verifying fuel purchases and indicating the amount of Wisconsin fuel tax paid.
(2) Adding machine tapes showing how you calculated the gallon totals entered on line 12 below.
If your invoices cover this period:
Use this tax rate:
REFUND COMPUTATION SCHEDULE
April 1, 1999 – March 31, 2000
25.8¢ per gallon
Invoice Caution: Do not include fuel purchases when the invoice
April 1, 2000 – March 31, 2001
26.4¢ per gallon
states that the fuel is exempt from the Wisconsin fuel tax.
11. Motor vehicle fuel tax rates.
FUEL TAX RATE
FUEL TAX RATE
Indicate the rates that apply to the invoices you submit with
_______ . ____ ¢ per gallon
_______ . ____ ¢ per gallon
this claim. Enter the earlier rate in the left two columns.
FUEL TYPES
Gasoline
Undyed Diesel
Gasoline
Undyed Diesel
12. Total gallons purchased and used at each fuel rate (do not
include any tax-exempt purchases of fuel or dyed diesel fuel)
13. Gallons included on line 12 used in licensed cars and trucks
14. Gallons on which refund is claimed (line 12 less line 13)
15. Compute Refund (multiply gallons on line 14 in each column
by the fuel tax rate on line 11). Enter total refund on line 16b.
16a. TOTAL GALLONS FROM LINE 14
16b. TOTAL REFUND CLAIMED
(enter whole gallons only)
Add all columns on line 14
____________________________
Add all columns on line 15
$ _______________________
17. Equipment in which motor vehicle fuel was used for off-road purposes (check all boxes that apply).
Tractors
Combines
Bobcats
Skid Loaders
Haybines
Other (please describe):
__________________________________________________________________________
CAUTION: FUEL TAX IS NOT REFUNDABLE ON FUEL PLACED INTO LICENSED MOTOR VEHICLES even if the licensed
vehicles are used to perform farming activities like picking up supplies in town or checking on animals or crops in the fields.
HOW YOU CAN AVOID FILING REFUND CLAIMS ON FUEL PLACED INTO OFF-ROAD FARM EQUIPMENT...
Dyed diesel fuel may be purchased tax-exempt but it cannot be placed in licensed motor vehicles or mixed with undyed diesel fuel.
Gasoline can be purchased tax-exempt in amounts of 100 gallons or more if delivered by your supplier. You must execute an
exemption certificate (MF-209) with your supplier to purchase gasoline tax-exempt for off-road use.
DECLARATION: 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)
Business Telephone No.
Date
(
)
MF-003W (R. 2-00)
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