Form Boe-770-Dz - Claim For Refund On Nontaxable Sales And Exports Of Diesel Fuel -State Of California
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5BOE-770-DZ (S1) REV. 2 (4-03)
STATE OF CALIFORNIA
BOARD OF EQUALIZATION
CLAIM FOR REFUND ON NONTAXABLE SALES AND EXPORTS OF DIESEL FUEL
BOARD USE ONLY
RA-B/A
AUD
REG
CLAIM PERIOD
/
/
THROUGH
/
/
RR-QS
FILE
REF
[
]
YOUR ACCOUNT NO.
FOID
EFF
BOARD OF EQUALIZATION
FUEL TAXES DIVISION
PO BOX 942879
SACRAMENTO CA 94279-2050
READ INSTRUCTIONS
BEFORE PREPARING
You may use this form to file a claim for refund of tax paid on undyed diesel fuel exported for use outside the state, sold to the U.S.
Government, sold to train operators for use in a diesel-powered train or for other off-highway use, or used in your operations for
purposes other than propelling vehicles on the highway of this state.
Enter the beginning and ending dates of the period covered by this claim as mm/dd/yy in the box above.
REPORT WHOLE
REPORT OF DIESEL FUEL TRANSACTIONS
GALLONS ONLY
1.
Undyed diesel fuel purchased in California tax-paid (enter from Schedule 1A)
1.
2.
Dyed and undyed diesel fuel purchased ex-tax for sale or use in California (enter from Schedule 2A)
2.
REPORT WHOLE
CLAIM FOR REFUND OF TAX-PAID DIESEL FUEL
GALLONS ONLY
3.
Tax-paid fuel exported (enter from Schedule 13A)
3.
4.
Tax-paid fuel sold to the United States Government (enter from Schedule 13C)
4.
5.
Tax-paid fuel sold to train operators (enter from Schedule 13G)
5.
6.
Tax-paid fuel used in your operations for purposes other than to operate motor vehicles on-highway
6.
7.
Total gallons of tax-paid diesel fuel to be refunded (add lines 3 through 6)
7.
8.
Tax rate
8.
.18
9.
AMOUNT OF REFUND (multiply line 7 by line 8)
9.
$
CERTIFICATION
I, the undersigned, certify that, to the best of my knowledge, all information on this claim and any accompanying documents is true,
correct, and complete. I further certify that the diesel fuel covered by this claim did not show any visible evidence of dye, and that
the diesel fuel tax was not included in the sales price of the diesel fuel covered by this claim and was not collected from the
purchasers. In addition, I certify that I have in my possession valid exemption certificates from train operators for transactions
covered by this claim, and that, to the best of my knowledge, all the information on the certificates is true and correct.
YOUR SIGNATURE AND TITLE
DATE
TELEPHONE NUMBER
CONTINUE
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