Form Wv/mft-501c - Distributor Schedule Of Disbursements - 2003
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1
2WEST VIRGINIA STATE TAX DEPARTMENT
WV/MFT-501- C
Org. 11/03
INTERNAL AUDITING DIVISION
P O BOX 2991
Charleston, WV 25330-2991
(304) 558-8500
DISTRIBUTOR SCHEDULE OF DISBURSEMENTS
FEIN/SSN
NAME
SCHEDULE NUMBER
MONTH/YEAR
5
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)
Mode
Point of
Date
Document
Gross Gallons
Net Gallons
INVOICED
Motor Fuel
Motor Fuel
Purchaser’s
Purchaser’s
Origin
Destination
Shipped
Number
GALLONS
Transporter’s
Transporter’s
Name
FEIN/SSN
Name
FEIN/SSN
Sub Total
GRAND TOTAL ON INVOICED GALLONS
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