Form Wv/mfr-14 - Worksheet - Schedule B - Motor Fuel Exise Tax Casualty Loss Statement
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1WV/MFR-14 - Worksheet
REV 03/11
WEST VIRGINIA STATE TAX DEPARTMENT
Tax Account Administration Division, Excise and Support Unit
PO BOX 2991
CHARLESTON, WV 25330-2991
Schedule B
Motor Fuel Excise Tax
Casualty Loss Statement
(Submit with the filing of the Motor Fuel Refund Application MFR-14)
PLEASE PRINT OR TYPE
FEIN or 8 Digit Acct No:
Contact Person:
Name:
Telephone:
Ext:
DBA:
PERIOD ENDING: ______________________________
Address:
City:
State:
Zip:
1.
State reason for this claim, including specific location where loss occurred. If additional space is required, use reverse side.
Gallons Lost:
Fuel Type:
2.
Date of Loss:
3.
Has tax been paid on lost fuel?
Yes
No
4.
Provide name and address of person having first hand knowledge of the loss.
If yes, attach a copy of fuel purchase invoice(s)
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