Form 04-535 - Reseller Claim For Refund Motor Fuel Tax - Alaska Department Of Revenue Page 3

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Alaska Department of Revenue
Reseller Claim for Refund
Schedule of Gallons Delivered Tax-Off
Range of Dates for Fuel Purchased
Name:_________________________________________________
From:
/
/
To:
/
/
EIN or SSN:________________Qualified Dealer No:___________
Schedule Type: (Check only one box)
Fuel Type: (Check only one box)
Qualified dealer-Gallons delivered tax-off to licensed qualified dealers
65 Gasoline
Bulk fuel sales-Gallons delivered to common storage tanks for
124 Gasohol
foreign/domestic flights (jet fuel only)
125 Aviation Gasoline
Foreign flights-Gallons delivered to air carriers exclusively for
130 Jet Fuel
foreign flights (jet fuel only)
160 Diesel
Customer
Qualifed Dealer
Tax-Off
Customer Name
Federal EIN
Number
Gallons
Total Gallons
Attach this schedule to your Reseller Claim for Refund. Use additional sheets as necessary.
Form 04-535.3 (New 6/97)

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