WEST VIRGINIA STATE TAX DEPARTMENT
WV/MFT-504 G
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 – 5H
MONTH/YEAR
Exempt motor fuel sold for a taxable
purpose to unlicensed distributors, and
licensed suppliers
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 2 of Worksheet A