Form 04-535 - Reseller Claim For Refund Motor Fuel Tax - Alaska Department Of Revenue Page 2

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Alaska Department of Revenue
Reseller Claim for Refund
Schedule of Exported Fuel
Range of Dates for Fuel Purchased
Name:_________________________________________________
From:
/
/
To:
/
/
EIN or SSN:________________Qualified Dealer No:___________
Fuel Type: (Check only one box)
65 Gasoline
130 Jet Fuel
124 Gasohol
160 Diesel
125 Aviation Gasoline
Customer
State/Country
Date
Invoice
Invoice
Invoiced
Customer Name
Federal EIN
of Destination
Shipped
Date
Number
Gallons
Total Gallons (Carry forward to page 1, line 2)
Attach this schedule to your Reseller Claim for Refund. Use additional sheets as necessary.
Form 04-535.4 (New 6/97)

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