Form Wv/mft-511b - Exporter Schedule Of Disbursements - 2003
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1
2WEST VIRGINIA STATE TAX DEPARTMENT
WV/MFT-511 B
Org. (5/03)
INTERNAL AUDITING DIVISION
P O BOX 2991
Charleston, WV 25330-2991
(304) 558-8500
EXPORTER SCHEDULE OF DISBURSEMENTS
FEIN/SSN
NAME
MONTH/YEAR
SCHEDULE NUMBER – 7B
EXPORTED SALES
West Virginia tax paid
PRODUCT INFORMATION (CHECK APPLICABLE BOX)
MODE OF TRANSPORTATION
(COMPLETE SEPARATE SCHEDULES FOR EACH PRODUCT TYPE YOU DELIVER)
CODES
□ 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 ___________
□ 124 – Gasohol
□ 142 – Kerosene – Undyed
Product Code __________
□ 065 – Gasoline
PRODUCT DISBURSEMENT INFORMATION
(1)
(2)
(3)
(4)
(5)
(7)
(8)
(9)
(10)
(11)
(6)
Motor Fuel
Motor Fuel
Mode
Point of
Purchaser’s
Date
Document
Gross Gallons
Net Gallons
INVOICED
Purchaser’s
Origin
Destination
Shipped
Number
Transporter’s
Transporter’s
Name
FEIN/SSN
GALLONS
Name
FEIN/SSN
SUB TOTAL
SUBMIT IN DUPLICATE
GRAND TOTAL OF INVOICED GALLONS (Transfer to Lines 1 and 2)
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