Form Mf-003w - Agricultural Users - Off-Road Fuel Tax Refund Claim
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2FYI - click in 'Section A: Legal Name OR check address change box if
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applicable and tab through. Use mouse to check applicable boxes or Enter.
FILE THIS CLAIM WITH:
AGRICULTURAL USERS - OFF-ROAD FUEL TAX REFUND CLAIM
Wisconsin Department of Revenue
Post Office Box 8900
FILING REMINDERS...
Madison, WI 53708-8900
● Claims must be filed within one year from the date fuel is purchased.
Have questions? Contact us at:
● Provide all information requested to avoid delays in processing your claim.
(608) 266-7363 or 266-6701
● No refund will be issued on less than 100 gallons.
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
Section A:
Federal Employer ID No.
AND/OR
Social Security No. (if you are
Legal Name
(FEIN)
a sole proprietor)
__ __ – __ __ __ __ __ __ __ ½
__ __ __ – __ __ – __ __ __ __
Mailing Address – Street or PO Box Number
City
State
Zip Code
Type of Organization (check one)
Date of Incorporation or Registration: _________________
Wisconsin County of Business
Location
1. ____ Individual
3. ____ Wisconsin corporation
____ LLC - Taxed as partnership
2. ____ Partnership
4. ____ Out-of-state corporation
____ LLC - Taxed as corporation
5. ____ Other: describe_______________
____ LLC – Single member LLC only
__________________________
If fuel purchases cover more
Section B:
DATES OF FUEL PURCHASES COVERED BY THIS REFUND CLAIM CAUTION ä
than one fuel tax rate period, you
Date of first
Date of last
must submit a separate refund
Purchase è ___________________________ purchase è _____________________________
claim for each period.
MOTOR VEHICLE FUEL TAX RATES
USE A SEPARATE CLAIM FORM
Period Covered by Your Purchases
Fuel Tax Rate
April 1, 2003 through March 31, 2004
28.5¢ per gallon
FOR EACH FUEL TAX RATE PERIOD
April 1, 2004 through March 31, 2005
29.1¢ per gallon
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 1 below.
Section C: REFUND COMPUTATION SCHEDULE
**ENTER WHOLE GALLONS ONLY**
Invoice Caution: Do not include fuel purchases when the invoice states that the fuel is exempt from the Wisconsin fuel tax.
FUEL TYPES:
Gasoline
Undyed Diesel
1. Total gallons purchased and used by fuel type (do not include tax-exempt purchases of fuel
or dyed diesel fuel)
2. Gallons included on line 1 used in licensed cars and trucks by fuel type
3. Gallons on which refund is claimed by fuel type (line 1 less line 2)
4. Motor vehicle fuel tax rate (enter one rate from schedule above)
5. Compute Refund (multiply gallons on line 3 in each column by the fuel tax rate entered on
line 4. Enter total refund on line 7/8
6.
TOTAL GALLONS FROM LINE 3
7. & 8.
TOTAL REFUND CLAIMED
Add all columns on line 3 ____________________________
Add all columns on line 5 $ ________________________
Section D:
Equipment in which motor vehicle fuel was used for off-road purposes (check all boxes that apply).
Tractors
Combines
Bobcats
Skid Loaders
Haybines
è
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. 3-04)
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