Form 80-005 - Iowa Motor Fuel Tax Refund Permit Application Form - 2005

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Iowa Department of Revenue
Iowa Motor Fuel Tax Refund Permit Application
80-005 (1/12/06)
To file for a refund, you must claim at least $60. Rather than
MAIL COMPLETED APPLICATION TO...
apply for a refund permit, you may take credit on your Iowa
Iowa Department of Revenue
income tax return in some instances.
Compliance Division, Fuel Tax Unit
PO Box 10456
Starting date of first invoice to be claimed: _____________
Des Moines, Iowa 50306-0456 OR FAX TO
515/281-3756
I. LOCATION NAME/ADDRESS
IV. TYPES OF REFUND PERMITS
Federal ID Number (if any): ______________________________
Check all that apply.
If you are in the process of applying for a
Agricultural Production (21)
FEIN, write “applied for” on this line.
Federal Government (31)
Social Security Number: _________________________________
State Government (32)
Owner (Legal) Name: ___________________________________
Other Political Subdivision (county, city, school) (33)
Business (Trade) Name: _________________________________
Urban Transit System (34)
Street Address: ________________________________________
Regional Transit System (35)
Do not give a post office box.
Native American Tribe (36)
City: ____________________ State: _____ Zip: _____________
Contract Carrier (41)
If in Iowa, County: _____________________________________
Commercial Fishing (51)
Home Heating (52)
County Number: ______________________________
Extract/Process Natural Deposits (53)
Phone #: ___________________________ Ext. _______
Denaturing Alcohol (54)
Fax #: _____________________________
Commercial: Check the appropriate boxes below (60)
E-mail: _____________________________
Reefer Unit
Pumping Credits – dry products
II. MAILING NAME/ADDRESS
Pumping Credits – wet products
If your mailing address is different than the location of your business,
Idle Time – please submit study
complete this section.
Power Takeoff – please submit study
Name: _______________________________________________
Off Road
Mailing Address: ______________________________________
Export of Tax Paid Fuel
Ready Mix
City: ____________________ State: _____ Zip: _____________
Solid Waste
Phone #: ___________________________ Ext. _______
Refund Agent (70)
Fax #: _____________________________
Number of clients: ______ Attach form 80-015.
E-mail: _____________________________
Reefer Unit
Pumping Credits – dry products
III. TYPE OF OWNERSHIP (check one)
Pumping Credits – wet products
Sole Proprietor
Partnership
Idle Time – please submit study
Power Takeoff – please submit study
Corporation
Association
Government
Limited Liability Co.
V. SIGNATURE
FOR OFFICE USE ONLY
This application must be signed by the owner, one of the
partners or a corporate officer.
PERMIT NUMBER
Signature: ____________________________________________
_________________________________
Print name here: _______________________________________
_________________________________
_________________________________
Social Security Number: _________________________________
_________________________________
Date: _______________________
Approval Initials: ____________________
Continue on other side

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