Form Mf-016 - Distributor Claim For Tax Refund Of Uncollectible Wisconsin Motor Vehicle Fuel Taxes

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MF-016: DISTRIBUTOR CLAIM FOR TAX REFUND OF
UNCOLLECTIBLE WISCONSIN MOTOR VEHICLE FUEL TAXES
Section 1
Please print or type
1. Legal Name of Claimant (individual, partnership, corporation) 2. Business Name
3. FEIN or SSN (if an individual or sole proprietor
5. City
6. State
7. Zip Code
4. Mailing Address - Street or PO Box
8. Business Telephone Number
(
)
Section 2
(1)
(3)
(4)
(5)
(7)
(8)
(2)
(6)
Date of
Gallons
Customer’s Name,
Type of Customer
Sales Invoice
Type of
Date Wrote Off
Uncollectible
Address, and FEIN/SSN
(check box)
Sale
Number
Product
As Uncollectible
Sold
Fuel Tax
Distributor
Gasoline
$
Retail dealer
Undyed diesel
Distributor
Gasoline
Retail dealer
Undyed diesel
Distributor
Gasoline
Retail dealer
Undyed diesel
Distributor
Gasoline
Retail dealer
Undyed diesel
Distributor
Gasoline
Retail dealer
Undyed diesel
Distributor
Gasoline
Retail dealer
Undyed diesel
Distributor
Gasoline
Retail dealer
Undyed diesel
Distributor
Gasoline
Retail dealer
Undyed diesel
(9) TOTAL TAX REFUND CLAIMED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
Section 3
DECLARATION: I declare under penalties of law that I have examined this refund claim and, to the best of my knowledge, it is true, correct, and complete.
Signature (do not print or type)
Contact Person (please print clearly)
Telephone Number
Date
(
)
MF-016 (R. 2-12)

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