Form Pet 375 - Wholesaler Application For Refund Of Tax On Motor Fuels - Tennessee Department Of Revenue - 2005
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1
2PET
375
TENNESSEE DEPARTMENT OF REVENUE
WHOLESALER APPLICATION FOR REFUND OF TAX ON MOTOR FUELS
Name of Claimant __________________________________________
SSN/FEIN ____________________________________
Location Address __________________________________________
Account No. ___________________________________
City, State, ZIP _____________________________________________
Claim Period:
Beginning ______________________
Mailing Address ___________________________________________
Ending ________________________
City, State, ZIP _____________________________________________
Date of Claim _________________________________
}
If this is an amended CLAIM FOR RE-
FUND, please check the box at right
Undyed Diesel
Part A. Limited User and Prepaid User Sales
Name of Limited User or Prepaid User
Account No.
No. Of Gallons Sold
__________________________________________________
____________
____________________________
__________________________________________________
____________
____________________________
__________________________________________________
____________
____________________________
__________________________________________________
____________
____________________________
__________________________________________________
____________
____________________________
__________________________________________________
____________
____________________________
__________________________________________________
____________
____________________________
__________________________________________________
____________
____________________________
__________________________________________________
____________
____________________________
__________________________________________________
____________
____________________________
Total (Enter on Line 2 in Comput ation Section below)
____________________________
Part B. Is this a claim related to dye contamination of diesel fuel or a casualty loss ? (Yes/No) ___________
If yes, complete Part B schedule on the back of this form.
Gallons from
Computation of Refund Due
Part A or Part B
1. Gasoline Tax
$.196917 multiplied by
_______________
............................ (1) $ _________________
2. Diesel Tax
$.167379 multiplied by
_______________
............................ (2) $ _________________
3. Total Refund Due (add lines 1, and 2) ......................................................................................... (3) $ _________________
OATH OF TAXPAYER
Under penalties of perjury, I declare that I have examined this claim, and to the best of my knowledge and belief, it is true, correct,
and complete.
Name ___________________________________________
Title ___________________________________________
(Signature of Taxpayer, Officer, or Authorized Representative)
FOR OFFICE USE ONLY
CHECKED BY
DATE
APPROVED
REASON FOR REDUCTION
REFUND NO.
REDUCED
PROCESS COMPLETION DATE
INCREASED
APPROVAL
Approved Amount $ ______________
__________________________________________
________________________________________
_____________
Director or Designate
Commissioner of Revenue or Designate
Date
RV-R0009501
INTERNET (11-05)
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