Form Mf-012 - Vendor'S Claim For Motor Vehicle Fuel Tax Refund - Wisconsin Department Of Revenue
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Instructions
Wisconsin
MF-012 Vendor’s Claim for
Department of Revenue
Motor Vehicle Fuel Tax Refund
Use BLACK INK Only
(Including Petroleum Inspection Fee)
Section 1:
Legal Name
Tax Account Number
Business Name (DBA)
FEIN or SSN
Wisconsin County of Business Location
Mailing Address
City
State
Zip Code
/
/
Entity ceased business on
Check if address, name, or entity change
(MM DD YYYY)
Section 2: Type of Ownership
(check one)
Sole Proprietorship
Partnership. Indicate type ►
General
Limited
Limited liability partnership (LLP)
State of Incorporation ►
C Corporation ► Date of Incorporation
S Corporation
/
/
(mo/day/yr)
Limited liability company
Taxed as a corporation
Taxed as a partnership
Disregarded as an entity separate from its owner (single member LLC only)
Nonprofit organization
Governmental unit (describe)
Other (describe)
Section 3: DATES OF EXEMPT SALES INCLUDED IN THIS CLAIM
Date of FIRST exempt sale (MM/DD/CCYY) Date of LAST exempt sale (MM/DD/CCYY)
/
/
/
/
Section 4: REFUND COMPUTATION SCHEDULE
(Enter whole gallons only)
Column 1
Column 2
Column 3
Tax-Paid
Tax-Paid
Other
Gasoline
Undyed Diesel
Fuels
1 Motor vehicle fuel tax rate per gallon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
.309
.02
2 Petroleum inspection fee per gallon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
3 Sales to US government or its agencies (do not include sales to the State
of Wisconsin and Wisconsin municipalities or school districts) . . . . . . . . . . . . . . 3
Enter names of purchasers
Enter type of fuel for column 3
4 Sales of gasoline for off-road agricultural use (100 gal. min. per sale) . . . . . . . . 4
5 Sales for gasoline for off-road nonagricultural use (100 gal. min. per sale) . . . . 5
6 Sales to common motor carriers for the urban mass transportation of passengers
6
7 Sales of gasoline (for aircraft use) to general aviation fuel dealers or users
licensed with the Wisconsin Dept. of Revenue (100 gal. minimum per sale) . . . . 7
8 Sales of undyed diesel fuel for use as heating oil . . . . . . . . . . . . . . . . . . . . . . . . . 8
9 Other - please explain:
9
10 TOTAL GALLONS SOLD EXEMPT (add lines 3 through 9 in each column) . . . . 10
11 Add gallons on line 10, columns 1 and 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
12 Fuel tax refund (multiply total gallons on line 11 by fuel tax rate on line 1) . . . . . . . . . . . . . . . . . . . . . . . . . 12
13 Add gallons on line 3, columns 1, 2 and 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
14 Petroleum inspection fee refund (multiply total gallons on line 13 by fee on line 2) . . . . . . . . . . . . . . . . . . 14
15 TOTAL REFUND CLAIMED (add lines 12 and 14) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
$
Section 5: DECLARATION:
I declare that I have examined this claim, and to the best of my knowledge and belief, it is true, correct, and complete.
Signature (do not print or type)
Contact Person (please print clearly)
Telephone Number
Date
(
)
MF-012 (R. 1-12)
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