Form Mf-004 - Retailer'S Claim For Gasoline Tax Refund - Wisconsin Department Of Revenue

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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

Mailing Address

Wisconsin County of Business Location

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 corporation

Taxed as a partnership

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

.309

4 Fuel tax rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

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