INTERNATIONAL FUEL TAX AGREEMENT (IFTA) …

1 This report must be filed even if no activity has OPERATIONSP enalty (If late, 10% of tax due or $ , whichever is greater)Interest (Total from fuel Summary Report, Section 2, J)Tax Due or Credit (Total from fuel Summary Report Section 2, I) CALCULATIONT otal Tax Due or Credit, Penalty and Interest (Total of lines 1, 2 and 3) DUE (Pay in full with return) (Credit amounts totaling less than $ will not be refunded; Credit amount may only be carried for 8 quarters)REFUND REQUESTED (If not checked, any overpayment will be applied to next quarter)..Sign Your ReturnUnder penalties of perjury, I declare that I have examined this return (including accompanying schedules and statements) and to thebest of my knowledge and belief it is true and complete.

2 (Signature of Taxpayer)(Name of Taxpayer - Type or Print)(Title)(Date)(Person to Contact Concerning this Return)(Telephone Number)(Signature of preparer if other than taxpayer)(Address)(Date)(E-mail Address) INTERNATIONAL fuel TAX AGREEMENT (IFTA) QUARTERLY Ending:AMENDEDDue Date:LICENSE CANCELLATIONC ancellation Date:MMDDYYYY--CHECK BOX FOR ADDRESS CHANGE:NEW ADDRESS, IF CHANGED:STATE OF WEST VIRGINIA State Tax Department, Tax Account Administration DivP. O. Box 1682 Charleston, WV 25326-1682 Account #:City State ZipAddressNameO 6 0 0 9 0 9 0 1 WMAIL TO: WEST VIRGINIA STATE TAX DEPARTMENTTax Account Administration DivP.

3 O. Box 1682, Charleston, WV 25326-1682 FOR ASSISTANCE CALL (304) 558-3333 TOLL FREE (800) 982-8297 For more information visit our web site at: online at TypeTotal Miles TraveledTotal Gallons UsedAverage Fleet MPG ( ) 1 - fuel SUMMARY (Column A)(Column B)(Column C)110234567891112DI- DieselGA - GasolineGH - GasoholLP - Liquid PropaneNG - Liquid Natural GasCN - Compressed Natural GasE8 - E-85M8 - M-85BD - BiodieselET - EthanolMT- MethanolA5 - fuel TAX AGREEMENT (IFTA) QUARTERLY REPORTO 6 0 0 9 0 9 0 2 WAccount #:Complete this section Miles and Gallons must be rounded to the nearest WHOLE must be rounded to TWO decimal #:Enter two-character fuel code from Page (A) Jurisdiction * (Check box for Surcharge)(B) fuel Type **SECTION 2 - fuel SUMMARY REPORT123(C) Total Miles in Jurisdiction(D) Taxable Miles in Jurisdiction(E) Taxable Gallons (D/MPG)(F) Tax Paid Gallons in Jurisdiction(G) Net Taxable Gallons (E-F)(H) Tax Rate **(I) Tax / Credit Due(G x H)(J)Interest Due ** (K) Total DueI + 6 0 0 9 0 9 0 3 A000 INTERNATIONAL fuel TAX AGREEMENT (IFTA) QUARTERLY REPORTE nter two-character state to for current tax rates.

4 **Surcharge currently applicable to IN, KY, and VA (A) Jurisdiction * (Check box for Surcharge)(B) fuel Type **567(C) Total Miles in Jurisdiction(D) Taxable Miles in Jurisdiction(E) Taxable Gallons (D/MPG)(F) Tax Paid Gallons in Jurisdiction(G) Net Taxable Gallons (E-F)(H) Tax Rate **(I) Tax / Credit Due(G x H)(J)Interest Due ** (K) Total DueI + Totals (K)Interest rate will change annually.**See for interest Totals (C).Page Totals (D).Page Totals (E).Page Totals (F).Page Totals (I).Page Totals (G) #:Enter two-character fuel code from Page (A) Jurisdiction * (Check box for Surcharge)(B) fuel Type **SECTION 2 - fuel SUMMARY REPORT123(C) Total Miles in Jurisdiction(D) Taxable Miles in Jurisdiction(E) Taxable Gallons (D/MPG)(F) Tax Paid Gallons in Jurisdiction(G) Net Taxable Gallons (E-F)(H) Tax Rate **(I) Tax / Credit Due(G x H)(J)Interest Due ** (K) Total DueI + 6 0 0 9 0 9 0 3 A000 INTERNATIONAL fuel TAX AGREEMENT (IFTA) QUARTERLY REPORTE nter two-character state to for current tax rates.

5 **Surcharge currently applicable to IN, KY, and VA (A) Jurisdiction * (Check box for Surcharge)(B) fuel Type **567(C) Total Miles in Jurisdiction(D) Taxable Miles in Jurisdiction(E) Taxable Gallons (D/MPG)(F) Tax Paid Gallons in Jurisdiction(G) Net Taxable Gallons (E-F)(H) Tax Rate **(I) Tax / Credit Due(G x H)(J)Interest Due ** (K) Total DueI + Totals (K)Interest rate will change annually.**See for interest Totals (C).Page Totals (D).Page Totals (E).Page Totals (F).Page Totals (I).Page Totals (G)