Form Wv/mft-511 A - Exporter Schedule Of Disbursements - 2004
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1WV/MFT-511 A
EXPORTER SCHEDULE OF DISBURSEMENTS
REV 11/04
WEST VIRGINIA STATE TAX DEPARTMENT
L
INTERNAL AUDITING DIVISION
P O BOX 2991
Charleston, WV 25330-2991
(304) 558-8623; (304) 558-8624; (304) 558-8625; (304) 558-8626; (304) 558-8627
YOU MUST COMPLETE SEPARATE SCHEDULES FOR EACH PRODUCT TYPE AND PURCHASER
FEIN
NAME
MONTH/YEAR
SCHEDULE 7A
Exported sales - Destination state tax collected
SUBMIT THIS SCHEDULE IN DUPLICATE
PRODUCT INFORMATION (CHECK APPLICABLE BOX)
MODE OF TRANSPORTATION
□ 150 – #1 Fuel Oil
□ 228 – Diesel – Dyed
□ 054 – Propane
J – Truck
□ 125 – Aviation Gasoline
□ 160 – Diesel – Undyed
□ 224 – Compressed Natural Gas
R – Rail
□ 130 – Aviation Jet Fuel
□ 284 – Biodiesel – Undyed
□ 225 – Liquefied Natural Gas
□ 122 – Blending Components
□ 072 – Kerosene – Dyed
□ Other – Product Type ___________
B – Barge
□ 124 – Gasohol
□ 142 – Kerosene – Undyed
Product Code __________
□ 065 – Gasoline
PRODUCT DISBURSEMENT INFORMATION
(1)
(2)
(3)
(4)
(5)
(7)
(8)
(9)
(10)
(11)
(6)
Mode
Point of
Date
Bill of Lading
Transporter
Transporter
Purchaser
INVOICED
Purchaser
Loaded
Number
Origin
Destination
Net Gallons
FEIN
Name
GALLONS
FEIN
Gross Gallons
Name
TOTAL THIS PAGE
IMPORTANT NOTICE
:
BY PRODUCT TYPE
TOTAL ALL PAGES INVOICED GALLONS
You must obtain prior approval to submit your own of schedules
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