BOE-770-DU (S1) REV. 4 (4-03)
STATE OF CALIFORNIA
BOARD OF EQUALIZATION
BOARD USE ONLY
DIESEL FUEL CLAIM FOR REFUND ON NONTAXABLE USES
RA-B/A
AUD
REG
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THROUGH
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CLAIM PERIOD
FILE
RR-QS
REF
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YOUR ACCOUNT NO.
FOID
EFF
BOARD OF EQUALIZATION
FUEL TAXES DIVISION
PO BOX 942879
SACRAMENTO, CA 94279-2050
READ INSTRUCTIONS
READ INSTRUCTIONS
BEFORE PREPARING
BEFORE PREPARING
As a user of tax-paid diesel fuel for exempt purposes, you may use this form to file a claim for refund of tax paid on undyed diesel
fuel for the purposes described below.
Enter the beginning and ending dates of the period covered by this claim as mm/dd/yy in the box above.
REPORT WHOLE
REPORT OF DIESEL FUEL TRANSACTIONS
GALLONS ONLY
1.
Undyed diesel fuel purchased in California tax-paid (enter from Schedule 1A)
1.
2.
2.
Dyed and undyed diesel fuel purchased ex-tax for your own use in California (enter from Schedule 2A)
3.
Sales of undyed diesel fuel
3.
4.
Sales of dyed diesel fuel
4.
As provided in Section 60501 of the Diesel Fuel Tax Law, I hereby file a claim for refund of the tax (and for payment of the
applicable interest) for tax-paid undyed diesel fuel used for the purposes described below. This claim covers the period
identified above. Note: Please read the attached instructions before completing the claim.
REPORT WHOLE
CLAIM FOR REFUND OF TAX-PAID DIESEL FUEL
GALLONS ONLY
5.
5.
Gallons used in vessels
6.
6.
Gallons used in construction equipment exempt from registration operated off-highway
7.
7.
Gallons used off-highway in vehicles other than gallons reported on line 6
8.
Gallons used in the operation of power take-off (PTO) equipment
8.
Gallons used in vehicles operated on highways under the jurisdiction of the U.S. Department of
9.
9.
Agriculture
10.
Other nontaxable uses of diesel fuel (please group and explain each nontaxable use in a
10.
separate letter attachment)
11.
Total gallons of undyed diesel fuel used in a non-taxable purpose claimed (add lines 5 through 10)
11.
12.
Tax rate
12.
.18
13.
AMOUNT OF REFUND (multiply line 11 by line 12)
13.
$
CERTIFICATION
I, the undersigned, certify that, to the best of my knowledge, all information on this claim and any accompanying documents is
true, correct, and complete and that I am duly authorized to sign for the claimant. I further certify that the diesel fuel tax was
included in the sales price of the diesel fuel covered by this claim and that the diesel fuel covered by this claim did not contain
visible evidence of dye.
YOUR SIGNATURE AND TITLE
TELEPHONE NUMBER
DATE
CONTINUE
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Form Boe-770-dz - Claim For Refund On Nontaxable Sales And Exports Of Diesel Fuel -state Of California
Financial
Form Boe-770-dz2 - Instructions Claim For Refund On Nontaxable Sales And Exports Of Diesel Fuel
Financial
