Form Wv/mft-504 - West Virginia Motor Fuel Supplier/permissive Supplier Report Page 2
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2WV/MFT-504
WEST VIRGINIA MOTOR FUEL SUPPLIER/PERMISSIVE SUPPLIER REPORT
SECTION 1 - SUPPLIER/PERMISSIVE SUPPLIER INFORMATION
Report in whole gallons
Gasoline
Gasohol
Undyed Diesel
Clear Kerosene / Other
Net Taxable Gallons
1.
00
00
00
00
.
.
.
.
(Worksheet A)
2.
Combined Rate
0.3470
0.3470
0.3470
0.3470
Combined Rate Tax Due
3.
.
.
.
.
(Line 1 times Line 2)
Report in whole gallons
Dyed Diesel and Kerosene
Propane
Aviation Gasoline
Aviation Jet Fuel
Net Taxable Gallons At
4.
00
00
00
00
.
.
.
.
Var Rate (Worksheet A)
5.
Variable Rate
0.1420
0.1420
0.1420
0.1420
Variable Rate Due
6.
.
.
.
.
(Line 4 times Line 5)
* Exempt Fuel At Flat
7.
.
00
.
00
.
00
Rate (Worksheet A)
8.
Flat Rate
0.2050
0.2050
0.2050
* Tax Due - Exempt Fuel
9.
.
.
.
(Line 7 times Line 8)
Tax Due
10.
.
.
.
.
(Line 6 plus Line 9)
SECTION 2 - TAX CALCULATION
1. Grand Total Tax Due (Sum of Section 1 Line 3 and Line 10 all columns) Transfer Amount to Page 1 Line 1
.
* Exempt Fuel (Gallons) Sold or Used for Taxable Purpose (on-highway)
Check if applicable:
Schedule 7A / 7B Attached
Sign your return
Under penalties of perjury, I declare that I have examined this return (including accompanying schedules and statements) and to the best of my knowledge
and belief it is true and complete.
(Signature of Taxpayer)
(Name of Taxpayer - Type or Print)
(Title)
(Date)
(Person to Contact Concerning this Return)
(Telephone Number)
(Email Address)
(Signature of preparer other than taxpayer)
(Address)
(Date)
O
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0
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0
9
0
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