Receipt Summary Schedule - Record Of West Virginia Tax Paid Motor Fuel Purchases - Gasoline Only Page 2

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RECORD OF GASOLINE PURCHASES ONLY 
 
 
Date of Purchase 
QUANTITY 
Receipt/Invoice Number  
 PURCHASED FROM 
(List individual gallons) 
MM / DD / YY 
 
 
 
 
 
 
 
 
Subtotal of  page (Use additional pages if necessary) 

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