Form Wv/mft-501c - Distributor Schedule Of Disbursements

Form Wv/mft-501c - Distributor Schedule Of Disbursements - 2003 Page 2

INSTRUCTIONS

This schedule provides detail in support of the disbursement amount(s) shown on your monthly West Virginia Distributor Report (WV/GAS-501). Upon

prior approval, you may submit a schedule summarizing your receipts schedules, which must be formatted the same as the West Virginia Distributor

Schedule of Disbursements (WV/GAS-501C). If you choose to submit summary schedules, you must still submit the schedules of individual receipts.

Complete Separate Schedules for each Product Type and Group Purchasers Together.

FEIN/SSN

Enter the Federal Employment Identification Number (FEIN) or

Social Security Number (SSN) as shown on your monthly West Virginia Distributor Report.

Name

Enter the Name of the Company as shown on your monthly West Virginia Distributor Report.

Report Month/Year

Enter the Month and Year for which you are reporting.

Product Information

Check the applicable box for the product type accounted for on this schedule.

Motor Fuel Transporter’s Name

Enter the Name of the Company that transported the product.

Motor Fuel Transporter’s FEIN/SSN

Enter the FEIN or SSN of the company that transported the product.

Mode

Enter the code for the mode of transport used to move the product (see Mode of Transportation Codes on the front).

Point of Origin

Enter the IRS Terminal Control Number if the product was received from a terminal.

Otherwise, enter the City and State where the shipment originated.

Point of Destination

Enter the City and State where the product was delivered.

Purchaser’s Name

Enter the Name of the Company that purchased the product.

Purchaser’s FEIN/SSN

Enter the FEIN or SSN of the company that purchased the product.

Date Received

Enter the date (Month, Day, Year) the product was received.

Document Number

Enter the Terminal Manifest Number or Bulk Plant Withdrawal Invoice Number.

Gross Gallons

Enter the Gross Gallons you delivered.

Net Gallons

Enter the Net Gallons you delivered.

Invoiced Gallons

Enter the total number of Gallons Invoiced.

Sub Total

Enter the Total of Columns 9, 10 and 11 for this page of the report.

Grand Total

Enter the Grand Total of Column 11 for all pages of this report.

Form Wv/mft-501c - Distributor Schedule Of Disbursements - 2003 Page 2