Receipt Summary Schedule - Record Of West Virginia Tax Paidmotor Fuel Purchases
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1
2:
(If applicable)
Bulk Storage Capacity
Receipt Summary Schedule
IMPORTANT
_____________________
• 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.
Period Ending of Claim
• All receipts must be from a West Virginia location.
__________________________
• A separate application must be submitted for each
(Earliest Invoice Date)
(Last Invoice Date)
From
To
refund category; however, you may apply for more
: _________________
: __________________
Indicate Type of PTO Truck
than one product type on a single refund application.
Special Fuel Only
• Dispose of motor fuel refund applications which are
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
Casualty Loss:
Three years from end of month of loss
Contact Telephone No:
____________________________________
Poultry House:
Three years
Fiscal Year End: 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.)
Date of
Clear
(Undyed)
Receipt/Invoice
Dyed Diesel / Propane
Purchase
PURCHASED FROM
Diesel / Kerosene
Number
(List Individual Gallons)
(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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