Form Wv/mft-501d - Distributor Schedule Of On-Highway Exempt Fuel Disbursements - 2003
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2WV/MFT-501 D
Org. 11/03
WEST VIRGINIA STATE TAX DEPARTMENT
INTERNAL AUDITING DIVISION
P O BOX 2991
Charleston, WV 25330-2991
(304) 558-8500
DISTRIBUTOR SCHEDULE OF ON-HIGHWAY EXEMPT FUEL DISBURSEMENTS
FEIN/SSN
NAME
SCHEDULE NUMBER
MONTH/YEAR
5X
PRODUCT INFORMATION (CHECK APPLICABLE BOX)
MODE OF TRANSPORTATION CODES
(COMPLETE SEPARATE SCHEDULES FOR EACH PRODUCT TYPE YOU DELIVER)
□ 054 – Propane
□ Other – Product Type _______________
J – Truck
R – Rail
Product Code ______________
PRODUCT DISBURSEMENT INFORMATION
(1)
(2)
(3)
(4)
(5)
(7)
(8)
(9)
(10)
(11)
(6)
Motor Fuel
Motor Fuel
Mode
Point of
Purchaser’s
Date
Document
Gross Gallons
Net Gallons
INVOICED
Purchaser’s
Origin
Destination
Shipped
Number
GALLONS
Transporter’s
Transporter’s
Name
FEIN/SSN
Name
FEIN/SSN
Sub Total
–
GRAND TOTAL OF INVOICED GALLONS
Transfer to Line 4 of Report
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Parent category: Financial