Form Ref-1000a - Affidavit Form For Certification Of Tax Paid Invoices

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Indiana Department of Revenue
Form REF-1000A
Compliance Division
State Form 48389
Affidavit of Certification of Tax Paid Invoices
(R/ 02-02)
Name of Seller
D/B/A
Address
City/Town
State
Zip Code
FEIN Number
Social Security Number
R.R.M.C. Number
Business Telephone Number
E-mail Address (opitional)
(
)
The attached copies of (number of)
invoice(s) showing (name)
as purchaser represent sales of fuel on the dates shown on
the invoices by the supplier whose name appears above.
Listed below are invoice number(s), date(s), and gallonage of these purchases according to our records.*
Copies of all listed invoices are attached. These records are available for review at
.
Invoice #
Date
Gallons
Diesel/
Invoice #
Date
Gallons
Diesel/
.
Gasoline
Gasoline
(Circle One)
(Circle One)
D/G
D/G
D/G
D/G
D/G
D/G
D/G
D/G
Signed
Title
Subscribed and sworn to before me, this
day of
, 20
My commission expires:
*Attach additional sheets if necessary.
Notary Public

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