Form Mf-003w - Agricultural Users Off-Road Fuel Tax Refund Claim

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FILE THIS CLAIM WITH:
A
U
GRICULTURAL
SERS
O
R
F
T
R
C
FF-
OAD
UEL
AX
EFUND
LAIM
FILING REMINDERS...
•
Have questions? Call us at:
Claims must be filed within one year from the date fuel is purchased.
•
Provide all information requested to avoid delays in processing your claim.
•
No refund will be issued on less than 100 gallons.
U
Please print or type
(one name only please)
Federal Employer ID No.
AND
Social Security No.
(if you are
(FEIN)
a sole proprietor)
–
–
–
__ __
__ __ __ __ __ __ __
__ __ __
__ __
__ __ __ __
DATES OF FUEL PURCHASES COVERED BY THIS CLAIM
FARM ACREAGE
è
è
è
indicate date incorporated
À
Â
Á
Ã
Ä
*** ATTACH INVOICES TO YOUR CLAIM VERIFYING FUEL PURCHASES
AND THE AMOUNT OF WISCONSIN FUEL TAX PAID ***
If your invoices cover this period:
Use this tax rate:
REFUND COMPUTATION SCHEDULE
TWO TAX RATES
FUEL TAX RATE
FUEL TAX RATE
ë
FUEL TYPES
GASOLINE
CLEAR DIESEL
GASOLINE
CLEAR DIESEL
Compute refund
16a. TOTAL GALLONS FROM LINE 14
16b. TOTAL REFUND CLAIMED
(enter whole gallons only)
è
è
U
U
U
U
U
U
è
CAUTION:
LICENSED MOTOR VEHICLES
HOW YOU CAN AVOID FILING REFUND CLAIMS ON FUEL PLACED INTO OFF-ROAD EQUIPMENT...
•
Dyed diesel fuel
•
Gasoline
DECLARATION:
MF-003W (R. 7-98)

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