Form Wv/mft-50 - West Virginia Supplier/permissive Supplier Report
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1
2WEST VIRGINIA SUPPLIER/PERMISSIVE SUPPLIER REPORT
CHECK APPLICABLE BOXES
WV/MFT-504
□ Address has changed since prior report
REV 11/04
P O BOX 2991
□ Amended report
S
CHARLESTON, WEST VIRGINIA 25330-2991
□ Final Report for closed business
(304) 558-8623; (304) 558-8624; (304) 558-8625; (304) 558-8626; (304) 558-8627
Please Print or Type)
YOU MUST KEEP A COPY OF THIS REPORT FOR YOUR RECORDS
(
YOU MUST FILE THIS REPORT MONTHLY, EVEN IF NO ACTIVITY OCCURRED DURING THE MONTH
Period Ending (Month, Day and Year)
FEIN
NAME
Mailing Address
City
State
Zip Code
Due Date (Month, Day and Year)
Telephone Number
Fax Number
E-Mail Address
(
)
(
)
Dyed Diesel &
Aviation
Aviation
Clear Kerosene/
Gasoline
Gasohol
Undyed Diesel
Propane
COMPLETE BACK OF REPORT FIRST
Dyed Kerosene
Gasoline
Jet Fuel
r
Othe
Gallons @.11
Gallons @.11
Gallons @.11
Gallons @.11
NET TAXABLE GALLONS
1.
(Worksheet A Line 13)
Flat Rate Tax Due
2.
$
$
$
$
(Line 1 multiply by $0.2050)
Variable Rate Tax Due
3.
$
$
$
$
$
$
$
$
(Line 1 multiply by $0.11)
TAX DUE
4.
(Add Lines 2 and 3)
$
$
$
$
$
$
$
$
Exempt Fuel (Gallons) Sold or Used for
Gallons @.2050
5.
Gallons @.2050
Gallons @.2050
Gallon totals from Worksheet A – Line 2 plus Line 4
Taxable Purpose (on-highway)
Tax Due - Exempt Fuel Sold
6.
Line 5 multiplied by .2050
$
$
$
or Used for Taxable Purpose
TOTAL TAX DUE
$
$
$
$
$
$
$
$
7.
(Add Lines 4 and 6)
Add Line 7
GRAND TOTAL TAX DUE
(
– ALL COLUMNS)
$
8.
Distributor Discount @. 0075
Worksheet A – Total from Line 10)
.
$
9
(
Only if timely filed. Maximum $5,000
Administrative Discount
Line 8 multiply by 0.001)
(
$
10.
(Line 8 minus Lines 9 and 10)
GROSS AMOUNT DUE
$
11.
Enter Distributor’s Name:
Default Payment (Tax previously defaulted then paid)
$
12.
(Use additional sheet if necessary)
Must have submitted a Notice of Tax Payment Default Notice (WV/MFT- 512)
Default Deduction
(Amount not collected from Distributor/Importer)
$
13.
TOTAL AMOUNT DUE
(Line 11 plus Line 12 minus Line 13)
14.
$
□
CREDIT
$
15.
Previous Month $_________________ Period ended ____________ (MM/YY)
Exporter Return $___________________ Period ended ______________ \(MM/YY)
□
□
□
NET AMOUNT DUE
(Line 14 minus Line 15)
16.
$
ACH CREDIT
ACH DEBIT
CHECK ATTACHED
□
□
17. TOTAL REFUND/CREDIT DUE
(If Line 15 greater than Line 14)
$
DO YOU WANT LINE 17
REFUNDED?
CREDITED ON NEXT MONTHLY RETURN?
CERTIFICATION: I certify that I have read this report and all supporting documents and know their contents and that all information on both the report and supporting documents are true, accurate, and complete.
Authorized Representative’s Name (Please Print)
Authorized Representative’s Signature
Date
*O09110401W*
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