Form Av - Report Of Licensed General Aviation Fuel Dealer Or User
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Instructions
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Form AV
SUBMIT THIS REPORT EVEN
Report of Licensed General Aviation Fuel Dealer or User
IF YOU DO NOT OWE ANY TAX
Read instructions on reverse side before completing your report.
Report for
Due date
OWNERSHIP CHANGE:
Indicate date and type of change
Date of change
For use only by licensee named on the report.
Discontinued
Incorporated
New owners must apply for their own license.
SSNo
FEIN
Owner deceased
Partner added or dropped
Sold to
Legal Name
NAME / ADDRESS CHANGE
New Name: Attach explanation of name change
New name
Mailing Address - Street or PO Box Number
New location of business - street address
State
City
Zip
City, state, zip code
date inventory taken
1. Actual measured inventory at beginning of period
1.
(
)
2. Receipts during period (itemize below)
Attach additional sheets if necessary.
Name of Supplier
Type of Fuel
Date of Receipt
Invoice Number
Gallons
*X11107991*
Total gallons received (add gallons in last column and enter on this line)
2.
3.
3. Total beginning inventory and receipts (add lines 1 and 2)
>
4. Total taxable sales
4.
>
5. Total taxable own use
5.
>
6. Total nontaxable sales
6.
>
7. Total nontaxable own use
7.
8. Total disbursements (add lines 4, 5, 6 and 7)
8.
9. Book inventory at close of period (line 3 less line 8)
9.
date inventory taken
10.
(
)
10. Actual measured inventory at close of period
11.
11. Inventory discrepancy -- difference between lines 9 and 10
(see instructions)
12. Total taxable gallons (total of lines 4 and 5 above)
12.
Tax
13. Tax rate per gallon
13.
X
.06
Computation
14. TAX DUE -- multiply line 12 by tax rate on line 13
14.
I declare under penalties of law that the above information is true,
EFT
Check this box if you are paying the tax due
Payment
correct and complete to the best of my knowledge and belief.
on line 14 by electronic funds transfer (EFT).
Your signature
Date
Telephone
(
)
MF-011i (R. 4-07)
R525
Make your check payable and mail to:
For department use only
Wisconsin Department of Revenue
PO Box 8900
Madison WI 53708-8900
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Parent category: Financial