Form Av - Licensed General Aviation Fuel Dealer Or User Report
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AV
Licensed General Aviation
Form
Fuel Dealer or User Report
Tax Account Number
Wisconsin
Department of Revenue
FEIN / SSN
SUBMIT THIS REPORT EVEN
Month Covered (MM DD YYYY)
IF YOU DO NOT OWE ANY TAX
Use BLACK INK Only
Cancel my permit effective
Legal Name
Business Name (DBA)
(MM DD YYYY)
Check if address, name, or entity
Permit/Business Address
change
Check if this is an amended return
City
State
Zip Code
Check if correspondence is included
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 #
BOL #
Gallons
Make your check payable and mail to:
Inventory
Reconciliation
Wisconsin Department of Revenue
PO Box 8900
Madison WI 53708-8900
Total gallons received (add gallons in last column and enter on this line)
2.
3. Total beginning inventory and receipts (add lines 1 and 2) . . . . . . . . . . . . . . . . . .
3.
4. Total taxable sales . . . . . . . . . . . . . . . . . . . . .
4.
5. Total taxable use . . . . . . . . . . . . . . . . . . . . . .
5.
6. Total nontaxable sales . . . . . . . . . . . . . . . . . .
6.
7.
7. Total nontaxable use . . . . . . . . . . . . . . . . . . .
8.
8. Total disbursements (add lines 4, 5, 6, and 7) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9. Book inventory at close of period (line 3 less line 8) . . . . . . . . . . . . . . . . . . . . . . .
9.
10. Actual measured inventory at close of period. (Date inventory taken:
)
10.
11. Inventory discrepancy - line 9 less line 10 (see instructions). . . . . . . . . . . . . . . . .
11.
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 the tax rate on line 13 . . . . . . . . . . . . . . . . . . . . .
14.
DECLARATION: I declare under penalties of law that the above informa-
EFT
Check this box if you are paying the tax due
tion is true, correct, and complete to the best of my knowledge and belief.
Payment
on line 14 by electronic funds transfer (EFT).
Signature (do not print or type)
Contract Person (Please print clearly)
Telephone Number
Date
(
)
MF-011 (N. 8-11)
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