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

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Part A. Limited User and Prepaid User Sales
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Part B. Contaminated Fuel or Casualty Loss Refund
Reason for loss or contamination: __________________________________________________________________________________
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Date of loss or contamination: _________________________
Contaminated Product: ______________________________
B1. Number of Gallons Gasoline ________________________
Type of Tax - Paid Fuel Involved: ______________________
Total (Enter on lines 1, 2, & 3 in Computation Section on front)
Type of Non-Taxed Fuel Involved: _____________________
B2. Number of Gallons Diesel __________________________
Total (Enter on lines 1, 2, & 4 in Computation Section on front)Disposition of Contaminated Product: __________________________
INSTRUCTIONS FOR WHOLESALER APPLICATION OF REFUND OF TAX ON MOTOR FUELS
GENERAL INFORMATION
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.
INSTRUCTIONS
???(Will this instruction be necessary for RITS form?)
Part A
Limited User and Prepaid User Sales.
Part B
Contaminated Fuel:
Casualty Losses:
???

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