Casualty Loss/special Fuel Blending Error Form - Iowa Department Of Revenue And Finance
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1IOWA
Casualty Loss/Special Fuel Blending Error
d e p a r t m e nt o f R ev e n u e a n d F i n a n c e
Send this claim to: Iowa Department of Revenue and Finance
Name of
Schedule 82-011 (02/98)
Motor Fuel Unit
Claimant ______________________
Examination Section
P.O. Box 10456
Attach to Form 82-006
FEIN _________________________
Des Moines, IA 50306-0456
Exact location of loss
Cause of loss
Procedure followed in determining amount of loss
Bill of lading
Bill of lading
Gallons listed
I f l o s s o c c u r r e d w h i l e i n
No. of gallons
Type of fuel
Date of loss
date
number
upon request
t r a n s i t o r a t t h e t i m e o f
é
u n l o a d i n g , c o m p l e t e t h e
section at right, providing
é
From whom purchased - Company/Person, City, State
information from the bill of
lading (manifest) or invoice
and indicating your seller.
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