Form Wv/mfr-14 - West Virginia Motor Fuel Tax Refund Application Wv/mfr-14

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STATE OF WEST VIRGINIA

State Tax Department, Tax Account Administration Div

P.O. Box 2991

Charleston, WV 25330-2991

Name

Address

Account #:

City

State

Zip

WV/MFR-14

WEST VIRGINIA MOTOR FUEL TAX REFUND APPLICATION

rtL161 v 6-Web

Effective January 1, 2013, the motor fuel excise tax rate increased from 33.4 cents per gallon to 34.7 cents per gallon.

Returns and refund applications have been updated. Please use the correct rate for periods after January 1, 2013.

Period Ending

Please refer to the instructions before filling out this form.

FUEL TYPE (Check all that apply)

(MM-DD-YYYY)

If reporting “Other”, please specify type. Visit for applicable fuel types and further information.

Gasoline:

Clear Diesel:

Clear Kerosene:

Propane:

Other:

Check

only one category.

You may choose multiple fuel types within a category. Submit a separate application for additional categories.

OFF HIGHWAY:

CLEAR KEROSENE:

GOVERNMENT:

Agriculture:

Consumer:

Federal:

Off-Highway:

Retailer:

State:

Power Take-Off (PTO):

Local, County, other:

PROPANE:

OTHER:

Poultry House Consumer:

Casualty Loss:

Evaporation

TOTAL GALLONS CLAIMED FOR REFUND

(Enter totals from worksheet on reverse side)

Fuel Type

Gallons

Fuel Type

Gallons

Fuel Type

Gallons

Gasoline

Clear Kerosene

Other

Clear Diesel

Propane

REFUND AMOUNT CLAIMED

(Enter total refund from Section 5 on reverse side)

Sign Your Application

CAUTION: Please review this application and attachments before signing. Presenting a fraudulent application constitutes a felony.

I declare that I have examined this application and under penalties of perjury declare that to the best of my knowledge and belief it is true, correct, and

complete.

(Signature of Taxpayer)

(Name of Taxpayer - Type or Print)

(Title)

(Date)

(Person to Contact Concerning this Application)

(Telephone Number)

(E-mail Address)

MAIL TO: WEST VIRGINIA STATE TAX DEPARTMENT

Tax Account Administration Div

P.O. Box 2991, Charleston, WV 25330-2991

FOR ASSISTANCE CALL (304) 558-3333 TOLL FREE (800) 982-8297