Form Fut 20-A Claim For Reimbursement Of Motor Fuel Use Tax Illegally Or Erroneously Paid
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1Prescribed Form
FUT 20-A (Rev. 1/02)
P.O. Box 530= Columbus, OH 43216-0530
Claim for Reimbursement of Motor Fuel Use Tax
Illegally or Erroneously Paid
Social Security No.
Taxpayer’s Account No.
Federal ID No.
State File No.
Name of Claimant __________________________________________________________________________________
Address __________________________________________________________________________________________
Street Address
City, Village or RFD
State
Zip Code
For the Period From ______________________________________
to _____________________________________
(Both dates inclusive)
By an Illegal or Erroneous Assessment:
Assessment No. _______________ Amount
$ __________________
By an Illegal or Erroneous Payment ........................................................................ Amount
$ __________________
Total
$ __________________
Claimant shall state full and complete reasons for claiming the above refund in the following space:
(If additional space is needed, use reverse side.)
The above represents all claims covering the period specified above.
I declare under penalties of perjury that this claim, including any
Claimant – Do Not Use This Space.
accompanying schedules and statements, has been examined
by me and, to the best of my knowledge and belief, is a true,
correct and complete report.
Claim Received __________________________________
Claimant ______________________________________
To be completed by Agent __________________________
By ____________________________________________
Amount Agent recommends for refund: $ _____________
(Title)
Date __________________________________________
Agent’s Remarks
(Use reverse side for additional remarks.)
I have examined this claim and adjustments, if any, in
Agent ___________________________________________
computation have been explained to me by the Agent.
Approved ________________________________________
Signed __________________________________________
Date____________________________________________
Claimant or Agent
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