Receipt Summary Schedule - Record Of West Virginia Tax Paid Motor Fuel Purchases - Gasoline Only

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:
(If applicable)
Bulk Storage Capacity
IMPORTANT 
Receipt Summary Schedule  
 
 
_____________________ 
 
• Submit with WV Refund Application (WV/MFR-14)   
Record of West Virginia Tax Paid  
• Report in Whole Gallons
(Gallons) 
• If inventory is maintained: Use Inventory Worksheet
 
Motor Fuel Purchases 
: 
Location Fuel Was Consumed
(Schedule D) to calculate gallons for refund.
 
• All receipts must be from a West Virginia location.
 
Period Ending of Claim 
 
______________________________ 
• A separate application must be submitted for each
 
                         (Earliest Invoice Date)                        (Last Invoice Date) 
 
refund category; however, you may apply for more
Indicate Type of PTO Truck 
From
To
 
: _________________  
: __________________
than one product type on a single refund application. 
     
 
 
• Dispose of motor fuel refund applications which are
Gasoline Only 
         Cement Mix                  Garbage  
prior to effective date of September 2009. 
 
 
 
     (Off Highway/ PTO)      
Purchases Dated 
Due Date 
Period Ending         (check) 
 
8‐digit Acct # or FEIN:
  ___________________________________
March 31 
 
January 1 – March 31 
April 30 
 
June 30 
 
April 1 – June 30 
July 31 
Name
:  __________________________________________________ 
September 30 
 
July 1 – September 30 
October 31 
 
December 31 
 
October – December 31 
January 31 
 
 
 
 
Contact Name: ____________________________________________ 
Agriculture: 
 
12 months from date of purchase or delivery 
 
Contact Telephone No:  ____________________________________ 
Casualty Loss: 
 
Three years from end of month of loss 
 
Poultry House: 
 
Three years  
     
 
 
 Fiscal Yr Ending: June 30   (July 1 – June 30) 
Government: 
 (Last acceptable postmark date ‐ August 31)  
 
 
Do not submit receipts/invoices or billing statements.   
Retain receipts for at least three years. 
All refunds are subject to audit or review. 
(The right to receive a refund is not assignable.  No payment may be made to any person other than the original person entitled.) 
 
 
 
QUANTITY 
Date of Purchase 
Receipt/Invoice Number 
 PURCHASED FROM 
(List Individual Gallons) 
MM / DD / YY
 
 
 
 
SUBTOTAL
 
Total of  back page and any additional pages  
TOTAL REFUNDABLE GALLONS
   
(Transfer to the back of refund application – Calculation of Refund) 

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