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Form Rev-643 Mf - Motor Fuels Tax Reimbursement Claim Form For Undyed Diesel And Undyed Kerosene Used In Truck Refrigeration Units

REV-643 MF (11-07)

DO NOT WRITE HERE

Motor Fuels Tax

Reimbursement Claim Form for

Undyed Diesel and Undyed Kerosene

PA Department of Revenue

Bureau of Motor Fuel Taxes

Used in Truck Refrigeration Units

PO BOX 280646

Harrisburg, PA 17128-0646

Tele. (717) 783-9362

SEE INSTRUCTIONS ON REVERSE SIDE

Fax (717) 787-6261

Purpose Statement: Use this form to claim a reimbursement of Pennsylvania Motor Fuel Taxes paid on undyed diesel fuel or undyed

kerosene purchased in Pennsylvania and used exclusively in truck refrigeration units.

A. General Information

(Please Type or Print Clearly):

–

1. Carrier's Name

2. Address

3. City, State, ZIP Code

4. EIN or SSN

5. Indicate base state(s) for IFTA purposes

6. U.S. DOT Number

7. Indicate Number of truck refrigeration units on which this claim is calculated

8. Refund Period (Indicate year and check appropriate quarter):

Tax Year 20

and the quarter ended:

3/31

6/30

9/30

12/31

9. PA Sales/Use Tax License Number

(See General Instructions and Information on reverse side)

B. Refund Calculation:

1. Indicate gallons of undyed diesel fuel or undyed kerosene purchased in Pennsylvania tax paid that were placed into a separate sup-

ply tank and used exclusively for truck refrigeration. Show gallons by month:

Indicate Month

Gallons Purchased

(Show Whole Gallons Only)

2. TOTAL GALLONS CLAIMED FOR THE REFUND QUARTER

3. AMOUNT OF REIMBURSEMENT REQUESTED

Calculate the reimbursement amount using the rate table on the reverse side of this form.

NOTE: Copies of fuel purchase invoices for one of the months shown above or as otherwise directed by the Department must be

submitted with this claim.

C. Certification:

Under penalties prescribed by law, I hereby affirm that this claim has been examined by me and to the best of my knowledge, infor-

mation and belief is true and correct, and that no refund or credit of the tax herein claimed has been received from any other source.

Claimant's Printed Name

Claimant's Signature

Claimant's Title

(

)

(

)

Telephone Number

Fax Number

Date

Form Rev-643 Mf - Motor Fuels Tax Reimbursement Claim Form For Undyed Diesel And Undyed Kerosene Used In Truck Refrigeration Units

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