MF-015: CLAIM FOR GENERAL AVIATION
PETROLEUM INSPECTION FEE REFUND
Period of Claim:
(mm ccyy)
Print or type, clearly
Read instructions before completing.
1. Legal Name of Individual, Partnership or Corporation
2. FEIN or SSN (if sole proprietor)
3. Business Name
Telephone Number
Wis. County of Business Location
(
)
–
City
State
Zip Code
4. Mailing Address - Street or PO Box
5. Type of Organization (check one)
Date Incorporated:
1.
Individual
3.
Wisconsin corporation
5.
Other (describe)
2.
Partnership
4.
Out-of-state corporation
6. Do you sell to, trade, or exchange general aviation fuel with any other person or company (including all its various locations)?
Yes
No
If yes, please explain:
COMPUTATION OF GENERAL AVIATION ALLOWANCE
7. Purchases of general aviation fuel during the month covered by this claim (attach additional sheets if necessary)
Gallons Purchased
Invoice Number
Name of Supplier
Type of Fuel
Date Purchased
(enter whole gallons only)
a.
b.
c.
d.
e.
f.
g.
h.
i.
8. TOTAL GALLONS PURCHASED DURING THE MONTH (add gallons on line 7) . . . . . . . . . . . . . . . . . . . .
8.
9. LESS: Purchase Requirement (only general aviation fuel purchased in excess of one million
gallons during a month qualifies for this allowance) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(1,000,000)
9.
10. GENERAL AVIATION FUEL GALLONS QUALIFYING FOR THE PETEROLEUM INSPECTION
-1,000,000
FEE ALLOWANCE (line 8 less line 9) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10.
.02
11. ALLOWANCE FACTOR (2 per gallon) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11.
¢
12. TOTAL REFUND (multiply gallons
THIS IS THE AMOUNT
-20,000
on line 10 by allowance factor on line 11) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
OF YOUR REFUND
12. $
DECLARATION: I declare under penalties of law that the above information is true, correct, and complete to the best of my knowledge
and belief.
Signature (do not print or type)
Contact Person (please print clearly)
Telephone Number
Date
(
)
MF-015 (R. 1-12)