Form Wv/mft-508 A - Importer Schedule Of Tax-Paid Receipts - 2004
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1EXPORTER SCHEDULE OF DIVERSIONS
WV/MFT-511 C
INTO WEST VIRGINIA
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 11
MODE OF TRANSPORTATION
PRODUCT INFORMATION (CHECK APPLICABLE BOX)
□ 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 RECEIPT INFORMATION
(1)
(2)
(3)
(4)
(5)
(7)
(8)
(9)
(10)
(11)
(12)
(6)
Mode
Date
Bill of Lading
Gross
Net
INVOICED
Diversion
Transporter
Transporter
Point of
Purchaser
Purchaser
Received
Number
Gallons
Gallons
GALLONS
Number
Origin
Destinatio
Name
FEIN
Name
FEIN
n
TOTAL THIS PAGE
IMPORTANT NOTICE
:
You must obtain prior approval to submit your own schedules
TOTAL ALL PAGES INVOICED GALLONS ONLY
BY PRODUCT TYPE
Transfer to Lines 13 and 14 of Report
–
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