Form Wv/mfr-14 - Worksheet - Schedule A - Customer List - Sellers Of Propane To Poultry House Consumers

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WV/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
SELLERS OF PROPANE TO POULTRY HOUSE CONSUMERS
Schedule A
– Customer List
FEIN or 8 Digit Acct No:
This list must accompany the Motor Fuel Refund Application
WV/MFR-14 for all gallons of tax-paid propane sold to a
.
Poultry House Consumer
Name:
Note: To receive a motor fuel refund a current Exemption
.
Certificate must be on file for the Poultry House Consumer
Address:
Contact Person: __________________________________
City:
State:
Zip:
Telephone:_______________________________________
Business Registration
Certificate Number of
Customer
Customer
Poultry House
Date
Name
Address
Gallons Sold
Heating Consumer
(From Exemption Certificate)
Total Gallons Claimed For Refund (add all lines)
(Use additional pages if necessary)

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