Form Mf-27g - Application For Refund Of State Diesel Tax September 2000 printable pdf download

Form Mf-27g - Application For Refund Of State Diesel Tax September 2000

Do Not Write in this Space

Montana Department of Transportation

Accounting Services Bureau

PO Box 8019, Helena, MT 59604-8019

(406)444-7278 FAX: (406)444-6032 TTY: (406)444-7696

Date

Postmarked

Application for Refund of State Diesel Tax

For Federal, State, Local Governments and School Districts

Names Must Match Invoices

Name:

Address:

FED ID #:

City:

State:

Zip:

Phone #:

Instructions

1. All information requested on this application is required. Failure to complete the form will result in the return of the application and

delay your refund.

2. Based on postmark date of application, invoices must be submitted for a refund within thirty six (36) months of date of purchase.

3. Photocopied invoices must be listed on Schedule 3 on reverse side and submitted with application.

4. The name on this application must match the name on all invoices.

5. This claim must be signed in original or it will be returned to sender.

6. The fuel placed in the tank must be used exclusively by a government entity and the receipts must show that the fuel purchased was tax

paid (undyed).

7. If purchaser and applicant names are not the same, attach a signed statement declaring the names on the invoices and the applicant's name

are one in the same.

Schools & Government Only

Total Gallons

Refund Amount

Total Gallons

Total Refund

(From schedule 3)

Per Gallon

Amount $

X $0.2775

I hereby declare and represent that the above and foregoing is a true and correct statement showing diesel purchased and entirely consumed by the applicant;

that the invoices included and photocopies of the original purchase invoices received at the time of purchase and delivery; that said claim against the State of

Montana is just and wholly unpaid.

Signature

Date

By cooperative agreement, the Montana Department of Transportation exchanges tax information with other collecting agencies.

Alternative accessible formats of this document will be provided on request.

MF-27G V

Revision 9/2000