Form Wv/mft-511 B - Exporter Schedule Of Disbursements - 2004
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1WV/MFT-511 B
REV 11/04
EXPORTER SCHEDULE OF DISBURSEMENTS
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 7B
-
EXPORTED SALES
West Virginia tax paid
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
B – Barge
□ 122 – Blending Components
□ 072 – Kerosene – Dyed
□ Other – Product Type ___________
□ 124 – Gasohol
□ 142 – Kerosene – Undyed
Product Code __________
□ 065 – Gasoline
PRODUCT DISBURSEMENT INFORMATION
(1)
(2)
(3)
(4)
(5)
(7)
(8)
(9)
(10)
(11)
(6)
Gross Gallons
Net Gallons
Mode
Date
Bill of Lading
INVOICED
Transporter
Transporter
Seller
Point of
Purchaser
Loaded
Number
GALLONS
Name
FEIN
Origin
Destination
Name
TCN
(City/State)
TOTAL THIS PAGE
IMPORTANT NOTICE:
You must obtain prior approval to submit your own schedules
TOTAL ALL PAGES INVOICED GALLONS ONLY
Transfer to Lines 1 and 2
BY PRODUCT TYPE –
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