Form Wv/mft-503 B - Terminal Operator'S Schedule Of Disbursements (4a) (Page 2 of 2) in pdf

Form Wv/mft-503 B - Terminal Operator'S Schedule Of Disbursements (4a) Page 2

INSTRUCTIONS

This schedule provides detail in support of the disbursement amount(s) shown on your monthly West Virginia Terminal Operator’s Report (WV/GAS-503).

Upon prior approval, you may submit a schedule summarizing your disbursement schedules, which must be formatted the same as the West Virginia

Terminal Operator’s Schedule of Disbursements (WV/GAS-503B). If you choose to submit summary schedules, you must still submit the schedules of

individual disbursements.

Complete Separate Schedules for Each Product Type and Group Position Holders Together.

FEIN/SSN

Enter the Federal Employment Identification Number (FEIN) or

Social Security Number (SSN) as shown on your monthly West Virginia Terminal Operator’s Report.

Name

Enter the Name of the Company as shown on your monthly West Virginia Terminal Operator’s Report.

Terminal Control Number

Enter the Terminal Control Number assigned by the IRS.

Report Month/Year

Enter the Month and Year you are reporting.

Product Information

Check the applicable box for the product type accounted for on this schedule.

Carrier’s/Motor Fuel Transporter’s Name

Enter the Name of the Company that transported the product.

Carrier’s/Motor Fuel Transporter’s FEIN/SSN

Enter the FEIN or SSN of the company that transported the product.

Mode

Enter the code for the mode of transport used to move the product (see Mode of Transportation Codes on the front).

Point of Destination

Enter the IRS Terminal Control Code if the product was shipped to a terminal.

Otherwise, enter the City and State where the shipment was delivered.

Position Holder’s Name

Enter the Name of the Company that owns the product as shown on your terminal records.

Position Holder’s FEIN/SSN

Enter the FEIN or SSN of the position holder that owns the product as shown on your terminal records.

Date Shipped

Enter the date (Month, Day, Year) the product was shipped.

Document Number

Enter the Terminal Manifest Number or Barge Ticket Number.

Gross Gallons

Enter the Gross Gallons delivered.

Net Gallons

Enter the Net Gallons delivered.

Sub Total

Enter the Total of Columns 9 and 10 for this page of the report.

Grand Total

Enter the Grand Total of Column 10 for all pages of this report.

Form Wv/mft-503 B - Terminal Operator'S Schedule Of Disbursements (4a) Page 2