Motor Fuels Tax Reimbursement Claim Form For Undyed Diesel And Undyed Kerosene Used In Truck Refrigeration Units printable pdf download

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

REV-643 MF (12-12)

DO NOT WRITE HERE

MOTOR FUELS TAX

REIMBURSEMENT CLAIM FORM FOR

UNDYED DIESEL AND UNDYED KEROSENE

BUREAU OF MOTOR AND

USED IN TRUCK REFRIGERATION UNITS

ALTERNATIVE FUEL TAXES

PO BOX 280646

HARRISBURG, PA 17128-0646

SEE REVERSE FOR INSTRUCTIONS.

Use this form to claim 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 this claim is based on: _____________________

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 ______________

B. Refund Calculation:

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

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

Month

Gallons Purchased

(Whole Gallons Only)

2. Total gallons claimed for the refund quarter

_________________

3. Amount of reimbursement requested

$_________________

Calculate the reimbursement amount using the Reimbursement Rate Table on the back of this form.

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

submitted with this claim.

C. Certification:

Under penalties prescribed by law, I affirm that this claim was examined by me and, to the best of my knowledge, information and belief,

is true and correct. Further, I affirm that no refund or credit of the tax claimed was received from any other source.

Claimant's Printed Name

Claimant's Signature

Claimant's Title

(

)

Telephone Number

Date

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

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