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

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PET
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 _________________________________
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Part A. Limited User and Prepaid User Sales
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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.
Computation of Refund Due
OATH OF TAXPAYER
(Signature of Taxpayer, Officer, or Authorized Representative)
FOR OFFICE USE ONLY
APPROVAL
Approved Amount $ ______________
__________________________________________
________________________________________
_____________
Director or Designate
Commissioner of Revenue or Designate
Date

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