Form Rmft-143 - Illinois Motor Fuel Tax Refund Claim For Overpayment Of Ifta Decals - Illinois Department Of Revenue

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Illinois Department of Revenue
Illinois Motor Fuel Tax Refund Claim
RMFT-143
for Overpayment of IFTA Decals
Attach the original refund claim, plus one copy. Keep a copy for your records.
Step 1: Identify yourself
1 _________________________________________________
3 ___ ___ ___ - ___ ___ - ___ ___ ___ ___
Name
Social Security no. (SSN)
or
_________________________________________________
___ ___ - ___ ___ ___ ___ ___ ___ ___
Number and street address
Federal Identifi cation no. (FEIN)
_________________________________________________
4 (___ ___ ___)___ ___ ___-___ ___ ___ ___
City
State
ZIP
Telephone no.
2 _________________________
IFTA Account no.
Step 2: Figure your refund
Attach one copy of your proof of payment for the decals
5
Decal year for which I overpaid:
___ ___ ___ ___
6 Decal numbers I received: _______________ - _______________
7
Number of decal sets I received:
_______________
8
Amount of payment I remitted for the decals
$ _______________
9 Amount of payment I should have remitted
$ _______________
(Line 7 x $3.75)
10 Amount of overpayment to be refunded:
$ _______________
(Subtract Line 9 from Line 8)
Step 3: Sign below
Under penalties of perjury, I state that I have examined this refund claim and, to the best of my knowledge, it is true, correct and complete.
_____________________________________________________
____ ____ / ____ ____ / ____ ____ ____ ____
Print Taxpayer/Responsible party's name
Title
Date
_____________________________________________________
____ ____ / ____ ____ / ____ ____ ____ ____
Signature of Taxpayer/Responsible party
Date
Mail your refund claim to:
MOTOR FUEL TAX REFUND SECTION
ILLINOIS DEPARTMENT OF REVENUE
PO BOX 19019
SPRINGFIELD IL 62794-9019
Reset
Print
This form is authorized as outlined by the Motor Fuel Tax Law and Environmental Impact Fee Law. Disclosure of this information is REQUIRED.
Failure to provide information could result in a penalty. This form has been approved by the Forms Management Center.
IL-492-4678
RMFT-143 (N-10/10)

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