Form Wv/mft-504h - Supplier/permissive Supplier Schedule Of Disbursements - 2003
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2WEST VIRGINIA STATE TAX DEPARTMENT
WV/MFT-504 H
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
MONTH/YEAR
SCHEDULE NUMBER – 7A
Exported sales
Destination state tax paid
PRODUCT INFORMATION (CHECK APPLICABLE BOX)
MODE OF TRANSPORTATION CODES
(COMPLETE SEPARATE SCHEDULES FOR EACH PRODUCT TYPE YOU DELIVER)
□ 150 – #1 Fuel Oil
□ 228 – Diesel – Dyed
□ 054 – Propane
J – Truck
□ 125 – Aviation Gasoline
□ 160 – Diesel – Undyed
□ 224 – Compressed Natural Gas
R – Rail
□ 130 – Aviation Jet Fuel
□ 284 – Biodiesel – Undyed
□ 225 – Liquefied Natural Gas
B – Barge
□ 122 – Blending Components
□ 072 – Kerosene – Dyed
□ Other – Product Type ___________
ST – Stationary Transfer
□ 124 – Gasohol
□ 142 – Kerosene – Undyed
Product Code __________
BA – Book Adjustment
□ 065 – Gasoline
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
SUBMIT IN DUPLICATE
GRAND TOTAL OF INVOICED GALLONS – Transfer to Line 2 Worksheet B
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