Form Wv/mft-503 B - Terminal Operator'S Schedule Of Disbursements (4a)
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1
2WEST VIRGINIA STATE TAX DEPARTMENT
WV/MFT-503 B
WV/MFT-503 B
Org. 11/03
Org. 11/03
INTERNAL AUDITING DIVISION
P O BOX 2991
Charleston, WV 25330-2991
(304) 558-8500
TERMINAL OPERATOR’S SCHEDULE OF DISBURSEMENTS (4A)
FEIN/SSN
NAME
TERMINAL CONTROL NUMBER
MONTH/YEAR
PRODUCT INFORMATION (CHECK APPLICABLE BOX)
MODE OF TRANSPORTATION CODES
(COMPLETE SEPARATE SCHEDULES FOR EACH PRODUCT TYPE DELIVERED)
□ 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 ___________
ST – Stationary Transfer
□ 124 – Gasohol
□ 142 – Kerosene – Undyed
Product Code __________
BA – Book Adjustment
□ 065 – Gasoline
PRODUCT DISBURSEMENT INFORMATION
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
Mode
Point of
Date Shipped
Document
Gross Gallons
NET GALLONS
Carrier’s/Motor Fuel
Carrier’s/Motor
Position Holder’s
Position’s Holder’s
Destination
Number
Transporter’s Name
Fuel Transporter’s
Name
FEIN/SSN
FEIN/SSN
Sub Total
–
GRAND TOTAL OF NET GALLONS
Transfer to Line 4 of Report
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Parent category: Financial