Form 04-544 - User Claim For Refund Motor Fuel Tax Page 5

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Alaska Department of Revenue
User Claim for Refund
Schedule of Invoices
Range of Dates for Fuel Purchased
Name:____________________________________________
From:
/
/
To:
/
/
EIN or SSN:_______________________________________
This schedule is required only if there are more than 10 invoices accompanying this refund claim. Attach original purchase invoices .
Fuel Type: (Check only one box)
65 Gasoline
130 Jet Fuel
124 Gasohol
160 Diesel
125 Aviation Gasoline
Gallons Purchased at
Supplier Name
84
54
4.74
3.24
24
Total Gallons
Attach this schedule to your User Claim for Refund. Use additional sheets as necessary.
Form 04-544.6 (Revised 6/97)

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