Form Wv/mft-504 D - Supplier/permissive Supplier Schedule Of Disbursements - 2004
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1SUPPLIER/PERMISSIVE SUPPLIER SCHEDULE OF DISBURSEMENTS
WV/MFT-504 D
REV 11/04
WEST VIRGINIA STATE TAX DEPARTMENT
INTERNAL AUDITING DIVISION
S
P O BOX 2991
Charleston, WV 25330-2991
(304) 558-8623; (304) 558-8624; (304) 558-8625; (304) 558-8626; (304) 558-8627
YOU MUST COMPLETE SEPARATE SCHEDULES FOR EACH PRODUCT TYPE AND PURCHASER
DISBURSEMENTS TO A DISTRIBUTOR WHO IS ALSO A SUPPLIER/PERMISSIVE SUPPLIER MUST BE REPORTED ON SCHEDULE 5E
FEIN
NAME
MONTH/YEAR
SCHEDULE 5D
Tax collected sales to Licensed Distributors and Licensed Importers
PRODUCT INFORMATION (CHECK APPLICABLE BOX)
MODE OF TRANSPORTATION
□ 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/Transporter
Carrier/Transporter
Mode
Point of
Purchaser
Date
Bill of Lading
Gross Gallons
Net Gallons
INVOICED
Purchaser
Name
FEIN
Number
Origin
Destination
GALLONS
Loaded
Name
FEIN
TOTAL THIS PAGE
IMPORTANT NOTICE
:
You must obtain prior approval to submit your own schedules.
TOTAL ALL PAGES INVOICED GALLONS ONLY
BY PRODUCT TYPE - TRANSFER TO LINE 3 OF WORKSHEET A
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