Form 22934 - Affidavit Of Lost Invoices
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2North Dakota Office Of State Tax Commissioner
Motor Fuel Tax Section
Affidavit Of Lost Invoices
Please complete, sign and submit with claim for refund of fuel taxes.
I, ________________________________________, certify that the original motor fuel purchase invoices listed
(Print Name of taxpayer filing claim)
below have been lost or cannot be supplied to me by the seller. Duplicate Copies Of The Invoices Are Attached
To This Affidavit.
____________________________________
Taxpayer's Signature
Subscribed and sworn to before me this ____ day of ______________________________, 20 ____.
(Notary Seal)
____________________________________
Notary Public Signature
Seller's Name ________________________________________________________________________
The seller certifies that the attached copies of motor fuel purchase invoices are the exact duplicates of the originals,
that each invoice has been paid in full by the purchaser of the fuel, and that the tax has been remitted to the Tax
Commissioner.
Please verify that the applicable duplicate invoices are attached by listing them in the space provided below. If
additional space is needed, continue the list on the reverse side of the form. If the invoice covers motor vehicle fuel
and if the tax is not listed on the invoice as a separate item, please enter it in the space provided. If the invoice
covers special fuels and if the tax is not listed as a separate item, please complete the price and tax information in
the spaces provided.
Invoice #
Date
Gallons
Price (Without Tax)
Tax
____________
____________
____________
$_______________
$_______________
____________
____________
____________
$_______________
$_______________
____________
____________
____________
$_______________
$_______________
____________
____________
____________
$_______________
$_______________
____________
____________
____________
$_______________
$_______________
____________
____________
____________
$_______________
$_______________
____________
____________
____________
$_______________
$_______________
____________
____________
____________
$_______________
$_______________
____________________________________
Seller Signature
Subscribed and sworn to before me this ____ day of ______________________________, 20 ____.
(Notary Seal)
____________________________________
Notary Public Signature
22934
(Revised 8-1995)
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