Form Mfr-43 - Application For Refund Non-Highway Use Of Taxable Clear Diesel Fue - Departament Of Revenue, State Of Georgia

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MFR-43
Mailing Address
(Rev. 2/08)
Application for Refund
Georgia Department of Revenue
Non-Highway Use of Taxable
Motor Fuel Tax Unit
Clear Diesel Fuel
Refund Section
1800 Century Center Blvd NE
Suite 8223
Atlanta, GA 30345-3205
FEIN:
SSN:
Period Covered: From:
To:
Claim may be filed for the 7 ½ cents per gallon excise tax on the non-highway use of taxable clear diesel fuel. Refund claim must be
filed within 18 months of the taxable clear diesel purchase.
1. Name of Applicant (Name In Which Clear Diesel Was Purchased):
DO NOT USE THIS SPACE
Approved Gallons @ 7 ½ cents
2. Doing Business As (dba):
Tax Examiner
3. Location Address:
4. Mailing Address:
5. City
State
Zip
6.
Quantity of Clear Diesel Fuel Purchased During Period:
____________________
(Total of Invoices Listed on Reverse Side)
7.
Plus Bulk Clear Diesel Fuel Inventory Brought Forward From Previous Claim: ____________________
8.
Less: Quantity of Clear Diesel on Hand at End of Period:
(_______________)
9.
Less: Quantity of Clear Diesel Used On-Highway
(_______________)
10. Total Clear Diesel Fuel Gallons on Which Refund is Claimed:
___________________
(Add Lines 6 & 7 and subtract Lines 8 & 9 = Line 10)
State Of Georgia: (county) ________________________
___________________________________ personally appeared before me who, being by me first duly sworn
(Claimant)
deposes and says under oath that he/she is applying for the refund of off-highway use of clear diesel fuel in the State of Georgia
and is true and correct that all of the above stated clear diesel fuel was used for non-highway purposes.
Claimant (Print Name): _______________________
Reason clear diesel used off-highway?
Signature of Claimant: _______________________
______________________________
Title of Claimant: ___________________________
______________________________
Date of Claim: ______________________________
______________________________
Contact Phone Number: ______________________

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