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MF-001: Fuel Tax Refund Claim
Use BLACK INK Only
Section 1
(Read instructions before completing the claim)
Legal Name
Tax Account Number
Business Name (DBA)
FEIN or SSN
Mailing Address
WI County Where Majority of Fuel was Purchased
Select WI County
City
State
Zip Code
/
/
Check if address, name, or entity change
Entity ceased business on
(MM DD YYYY)
Section 2
Type of Ownership (check one)
Sole Proprietorship
Partnership. Indicate type ►
General
Limited
Limited liability partnership (LLP)
State of Incorporation ►
C Corporation ► Date of Incorporation
S Corporation
/
/
(mo/day/yr)
Limited liability company
Taxed as a corporation
Taxed as a partnership
Disregarded as an entity separate from its owner (single member LLC only)
Nonprofit organization
Governmental unit (describe)
Other (describe)
Taxicab
Check one box:
Agricultural Off-Road
Nonagricultural Off-Road
Section 3 – Fuel Purchase Dates Covered By Claim
Date of FIRST purchase (MM DD CCYY)
Date of LAST purchase (MM DD CCYY)
Section 4 – Refund Computation Schedule
(no commas)
(a)
(b)
(c)
(e)
(f)
(d)
Fuel Type
Total Gallons
Gallons Used in
Fuel
Refund Amount
Gallons Claimed
Purchased
Taxable
Tax
By Fuel Type
as Exempt
by Fuel Type
Manner
Rate
(b-c)
(Multiply d x e)
1
Gasoline
0.309
2
Clear Diesel
0.309
3
CNG (Compressed Natural Gas)
0.247
LNG (Liquified Natural Gas)
4
0.197
LPG (Liquified Petroleum Gas)
5
0.226
6
Totals
7
Wisconsin Use Tax Due: Enter amount from Line 10, Section 6.
8
Net Refund Claimed (Line 6 minus Line 7, Column f)
Section 5 – DECLARATION:
I declare that I have examined this claim and attachments and to the best of my knowledge and
belief, it is true, correct, and complete. The fuel purchases on which this claim is based have been made within the last 12 months.
Contact Person (please print clearly)
Title
Date
Signature
Telephone Number
Email Address
(
)
MF-001 (R. 10-13)
Wisconsin Department of Revenue
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