Form 04-535 - Reseller Claim For Refund Motor Fuel Tax - Alaska Department Of Revenue

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Alaska Department of Revenue

DUE DATE: All claims must be filed

Income and Excise Audit Division

within one year from the date the fuel

Reseller

Claim for Refund

PO Box 110420

was purchased. (AS 43.40.050)

Motor Fuel Tax

Juneau, AK 99811-0420

DEPARTMENT USE ONLY

Send Refund to: (Name and Address)

EIN or SSN

Qualified Dealer Number

(if applicable)

FSN:

Business Location (City and State)

Range of Dates for Fuel Purchased

FROM:

Telephone Number

Fax Number

Type of Business/Occupation

E-mail address

TO:

Report all gallons in whole numbers

Requires that a schedule be attached (see instructions).

Aviation

Gasoline

Diesel

Gasohol

84 4

24 4

Gasoline

Jet Fuel

Highway

Marine

Highway

Marine

Refund

Exempt Fuel Sales

(Gallons)

Total

Qualified dealer

Exported

U.S. government

State or local government

Charitable institutions

Heating use

Public utilities

Stationary power plants

Bulk fuel sales

10.

Foreign flights

11.

Other (attach explanation)

12.

Total gallons (lines 1 - 11)

.047

.032

.08

.05

.08

.05

.08

.02

Rate

13.

Refund (line 12 X rate)

14. Total exempt fuel refund (add line 13, columns A through H)

Fuel Conversions (to a lower tax rate only)

15.

Highway to marine

16.

Highway to aviation

17.

Marine to aviation

18.

Gasohol 8

to 5

19.

Other (specify)

20.

Total gallons (lines 15 - 19)

.047

.032

.08

.05

.08

.05

.08

.02

Rate

21.

Refund (line 20 X rate)

22. Total conversion refund (add line 21, columns A through H)

23. Total claim for refund (add lines 14 and 22, column I)……………………………………………………………………………………………….. $

24. AMOUNT TO BE REFUNDED………………………………………………………………………………………………………………………..……… $

25. AMOUNT OF CREDIT to be applied to motor fuel tax (specify month and year) For the month of ______________year______…………….…..…………

I declare under penalty of unsworn falsification that I have examined this claim, and to the best of my knowledge and belief, the fuel was purchased on the dates

and in the amounts shown on each invoice, the fuel was sold in the manner set forth, the tax was previously paid, and no part of the tax refund claimed here has

already been refunded.

Signature

Printed Name

Title (Please print)

Date

Revenue Use Only

Examined by:

Approval:

Form 04-535 (Revised 6/97)

Remember to attach applicable schedules and purchase invoices