Form Mf-004 - Retailers Claim For Gasoline Tax Refund
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MF-004: Retailer’s Claim for
Gasoline Tax Refund
Use BLACK INK Only
Legal Name
Tax Account Number
Business Name (DBA)
FEIN/SSN Number
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)
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 partnership
Taxed as a corporation
Disregarded as an entity separate from its owner (single member LLC only)
Nonprofit organization
Governmental unit (describe)
Other (describe)
• DATES OF FUEL PURCHASES COVERED BY THIS CLAIM
Date of FIRST purchase (MM DD CCYY)
Date of LAST purchase (MM DD CCYY)
Claims must be filed
FILING REMINDER -
within one year from the date fuel is purchased.
GASOLINE
• REFUND COMPUTATION SCHEDULE
(Enter whole gallons only)
1 Total gallons of gasoline purchased. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2 Gallons not received into your retail storage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
3 Net gallons received into your retail storage (subtract line 2 from line 1) . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
4 Fuel tax rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
.309
5 Tax Paid - multiply gallons on line 3 by tax rate on line 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
6 RETAILERS ALLOWANCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
.005
7 REFUND CLAIMED - multiply amount on line 5 by allowance (.005) on line 6 . . . . . . . . . . . . . . . . . . . . . . 7
• RETAIL STATION LOCATION INFORMATION -
List each retail location receiving gasoline covered by this refund claim.
Station Name
Address (street and city)
Gallons Received
Total Gallons Received - must agree with amount on line 3 ►
DECLARATION: I declare that I have examined this claim and attachments and, to the best of my knowledge and belief, it is true,
correct, and complete. I am a retailer of the gasoline on which this claim is based. The gasoline was purchased by me within the
last 12 months and received into storage at my retail place of business.
Signature (do not print or type)
Contact Person (please print clearly)
Telephone Number
Date
(
)
MF-004 (R. 1-12)
Go to Page 2
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Parent category: Financial