Form Wv/mft-504 C - Supplier/permissive Supplier Schedule Of Disbursements - 2004
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1SUPPLIER/PERMISSIVE SUPPLIER SCHEDULE OF DISBURSEMENTS
WV/MFT-504 C
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
DO NOT USE THIS SCHEDULE FOR “DIRECT SHIPMENTS”
YOU MUST COMPLETE SEPARATE SCHEDULES FOR EACH PRODUCT TYPE AND PURCHASER
FEIN
NAME
MONTH/YEAR
SCHEDULE 5A
Tax collected sales to Unlicensed Distributors
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)
Mode
Point of
Date
Bill of Lading
Transporter
Transporter
Purchaser
INVOICED
Purchaser
Origin
Destination
Loaded
Number
GALLONS
Name
FEIN
Gross Gallons
Net Gallons
Name
FEIN
IMPORTANT NOTICE
TOTAL THIS PAGE
:
You must obtain prior approval to submit your own schedules.
TOTAL ALL PAGES INVOICED GALLONS ONLY
BY PRODUCT TYPE - TRANSFER TO LINE 1 OF WORKSHEET A
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