Form Mf-004 - Retailers Claim For Gasoline Tax Refund Page 2

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Page 2
MF-004 Gasoline Purchase Schedule
GASOLINE PURCHASES ONLY
1. Enter each gasoline purchase which qualifies for refund.
2. List your purchases in ascending order (oldest purchase first).
3. Enter the total gallons purchased on line 1 and attach an adding machine tape showing how you computed the totals.
Reminder: Purchases of diesel fuel do not qualify for refund.
If you do not provide all the information requested for each gasoline purchase listed on this schedule, your refund claim will be returned
to you for completion.
It is not necessary to submit invoices for the gasoline purchases you detail on this schedule.
Retail Station
Invoice
Purchase
Gallons
Name and Address of Supplier
Name and Address
Number
Date
Purchased
Wisconsin Department of Revenue
Return to Page 1

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