Form 04-544 - User Claim For Refund Motor Fuel Tax Page 2

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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

User

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

Gasoline

Jet Fuel

Highway

Marine

Highway

Marine

Refund

Exempt Fuel Use

(Gallons)

Total

Charitable institutions

Heating

Public utilities

Stationary power plants

Foreign flights

Other (attach explanation)

Total gallons (lines 1 - 6)

.047

.032

.08

.05

.08

.05

.08

.02

Rate

Refund (line 7 X rate)

9. Total exempt fuel refund (add line 8, columns A through H)

Fuel Conversions (to a lower tax rate only)

10.

Highway to marine

11.

Gasohol highway to marine

12.

Other (specify)

13.

Total gallons (lines 10 - 12)

.047

.032

.08

.05

.08

.05

.08

Rate

14.

Refund (line 13 X rate)

15. Total conversion refund (add line 14, columns A through G)

Non-Highway Use (Non-licensed Vehicles)

16.

Gallons used

.027

.012

.06

.03

.06

.03

.06

Rate

17.

Refund (line 16 X rate)

18. Total non-highway refund (add line 17, columns A through G)

19. Total claim for refund (add lines 9, 15 and 18, column I)………………………………………………………………………………………………… $

20. AMOUNT TO BE REFUNDED. ……………………………………………………………………………………………………………………………… $

21. 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, that the fuel was used in the manner set forth and that none of the fuel for which a non-highway tax refund is

claimed was used for operating an internal combustion engine in, or in conjunction with, a motor vehicle licensed to be operated on public ways and that no

part of the tax refund claimed has already been paid.

Signature

Printed Name

Title (Please print)

Date

Revenue Use Only

Examined by:

Approval:

Remember to attach applicable schedules and purchase invoices.

Form 04-544 (Revised 6/97)