Form Mf-001 - Fuel Tax Refund Claim Page 4
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4Fuel Purchase Schedule
(This page may be photocopied if additional schedules are needed).
The refund claim will be returned if incomplete information is provided.
List purchases by fuel type in date order (oldest first). At the end of each fuel type, provide a gallon total and also enter in Section 4, column b.
(a)
(b)
(c)
(d)
(e)
(f)
(g)
Fuel Type
Total
Invoice
Purchase
(gas, clear diesel,
Price Per
Gallons
Purchase
Name and Address of Supplier
Number
Date
CNG, LNG, LPG)
Gallon
Purchased
Price
-4-
MF-001 (R. 10-13)
Wisconsin Department of Revenue
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Parent category: Financial