Form Rmft-11-A - Illinois Motor Fuel Tax Refund Claim
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Illinois Department of Revenue
Illinois Motor Fuel Tax Refund Claim
RMFT-11-A
for tax paid on or after January 1, 2001
Step 1: Tell us the period covered by this claim
From:__ __ /__ __ __ __
To:__ __ /__ __ __ __
1
Write the period for which you are claiming a refund
Month/Year
Month/Year
Step 2: Identify yourself
______________________________
2
3
Federal employer identification number
__ __ - __ __ __ __ __ __ __
:
Name
or
______________________________
Social Security number: __ __ __ - __ __ - __ __ __ __
Address
______________________________
Phone number: (____)______ - __________
4
City, state, ZIP
5
If you were licensed as an Illinois distributor or supplier during
__ - __ __ __ __ __
the claim period, write your motor fuel license number.
Step 3: Figure your refund
Complete the columns below to list your tax-paid motor fuel gallons. Your refund claim must be based on the motor fuel you
used during the claim period in Line 1. If you were not a licensed distributor or supplier, you may claim the gallons on which
the tax was paid two years ago or less. Licensed distributors and suppliers may only claim the gallons on which the tax
was paid one year ago or less.
Column A
Column B
Column C
Tax rate
Column D
Total gallons
Highway
Nonhighway
per gallon
Net refund
gallons
gallons
6
Gasoline (from Step 6)
-
=
x
=
$
__________________
_________________
_________________
19¢ (.19)
______________
7
Undyed diesel fuel
(
from Step 7)
-
=
x
=
$
__________________
_________________
_________________
21 ½¢ (.215)
______________
.
8
=
$
Add the amounts in Lines 6 - 7, Column D, and write the result. This is your total refund claim amount
______________
________________
_______________
Official Use
Official Use
Step 4: Describe how you used the motor fuel listed in Step 3
9
What was the motor fuel used for? At what locations was it used? Describe in detail. Attach a separate sheet if needed.
Official use - do not write in this box
____________________________________________________________________
l___l___l___l___l___l___l___l___l
____________________________________________________________________
M
M
D
D
Y
Y
Y
Y
RT
IA
CL
WA
I.D.
____________________________________________________________________
1 - Agriculture
11 - Comm MV
2 - Construction
12 - Airport
____________________________________________________________________
3 - Industrial
13 - Refrigeration
4 - Railroad
14 - Power Take-off
5 - Marine
15 - Unintentional mixing
____________________________________________________________________
6 - Lawn
16 - Testing
7 - Distributor
17 - Dual Taxation
____________________________________________________________________
8 - Supplier
18 - Loss
9 - Manufacture
19 - Tug/Spotter
10 - R & D
____________________________________________________________________
Step 5: Describe the motor fuel you used for highway purposes
(from Step 3, Column B)
10
Number of miles traveled by motor vehicles
gasoline _______________
undyed diesel fuel _______________
11
Number of gallons removed from storage
gasoline _______________
undyed diesel fuel _______________
This form is authorized as outlined by the Motor Fuel Tax Law. Failure to disclose this information could result in
this form not being processed. This form has been approved by the Forms Management Center. IL-492-1542
RMFT-11-A Page 1 of 4 (R-8/05)
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