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For additional information, contact the Taxpayer Services Division in one of our Department of Revenue Offices:

Chattanooga

Jackson

Johnson City

Knoxville

Memphis

Nashville

(423) 634-6266

(731) 423-5747

(423) 854-5321

(865) 594-6100

(901) 213-1400

(615) 253-0600

Andrew Jackson Building

Suite 203

Suite 340

204 High Point Drive

Suite 209

3150 Appling Road

500 Deaderick Street

1301 Riverfront

Lowell Thomas Building

7175 Strawberry

Bartlett, TN

500 Deaderick Street

Parkway

225 Martin Luther King Blvd.

Plains Pike

Tennessee residents can also call our statewide toll free number at 1-800-342-1003.

Out-of-state callers must dial (615) 253-0600.

Part B. Contaminated Fuel or Casualty Loss Refund

Date of loss or contamination: __________________ Circumstances of loss or contamination: _____________________________

__________________________________________________________________________________________________________

For each incident of contamination, identify the:

Type of Contaminated Product: __________________

B1. Number of gallons gasoline __________________________________

Total (Enter on Line 1 in Computation Section on front)

Type of Non-Taxed Fuel Involved: ________________

B2. Number of gallons of tax-paid diesel lost or contaminated __________

Total (Enter on Line 2 in Computation Section on front)

Explain Disposition of Contaminated Product: ______________________________________________________________________

__________________________________________________________________________________________________________

INSTRUCTIONS FOR WHOLESALER APPLICATION OF REFUND OF TAX ON MOTOR FUELS

GENERAL INFORMATION

Sales to Limited Users and Prepaid Users. (67-3-420, Tennessee Code Annotated) A licensed wholesaler who sells tax paid motor fuel to a limited user

or a prepaid user (as defined in T.C.A. 67-3-1302) is entitled to a refund of the diesel tax paid pursuant to T.C.A 67-3-202. The claimant may file one claim

each month and otherwise is subject to the statute of limitations provided in T.C.A 67-3-421. Additionally, the licensed wholesaler’s entitlement to a

refund is not affected by the status of the customer’s limited user permit or prepaid user authorization, unless the wholesaler knows or has been notified

by the department or, in the exercise of reasonable care, should know that the customer is not entitled to use the permit or authorization with respect to

a particular purchase of fuel. Any claim for refund filed with the commissioner must be supported by additional documentation that sets forth

the customer’s name and address, account number, and federal employers identification number or social security number, as well as the

invoice or delivery ticket number(s) and number of gallons sold.

Contaminated fuels: (T.C.A. 67-3-415) Where taxable diesel fuel has been accidentally contaminated by dye, the owner of the product may file a claim

for refund for the diesel tax paid on the undyed fuel.

Casualty losses: (T.C.A. 67-3-416) Gasoline tax and diesel tax will be refunded covering loss of gallonage due to fire, flood, storm, theft or other causes

over which a vendor has no control. For losses over 1,000 gallons, the taxpayer must report the loss to the commissioner within three business days of

the date of the loss. For losses of 1,000 gallons or less, no immediate report is required, but the claim will be completed using Part B on the back of the

form in support of the computation the front of the form. With all losses and within sixty (60) days of the time of the loss, the vendor shall file

a claim and a written statement explaining the occurrence of the loss. Negligence, or any unlawful act, such as overloading a transport vehicle,

excessive speed or other like act by a vendor or his agent, which is contributory to a loss, shall invalidate the claim.

INSTRUCTIONS

Complete all information at the top of the form including claimant name, address, filing period, account number, location address, and social security

number or federal employers identification number. An amended claim must be noted by checking the amended claim block.

Part A

Limited User and Prepaid User Sales. Complete this part to specify total gallons of undyed diesel fuel sold to qualified limited users or

prepaid users without collecting the diesel tax. One claim per month may be filed. Additional documentation must be submitted as

explained above. Gallons qualifying for the refund must be from inventory on which the diesel tax has been paid.

Part B

Contaminated Fuel: See instructions above. Applies only to undyed diesel fuel contaminated by dye. Additionally, complete the appropriate

blanks and enter the total gallons claimed in B2.

Casualty Losses: See instructions above. Applies to motor fuels on which the gasoline tax or diesel tax has been paid. Additionally, complete

the appropriate blanks and enter the total gallons in B1 or B2. Gasoline gallons should be carried forward to the Computation section on the

front of the form on Line 1. Diesel gallons should be carried forward to the front of the form on Line 2.

Form Pet 375 - Wholesaler Application For Refund Of Tax On Motor Fuels - Tennessee Department Of Revenue - 2005 Page 2

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