Dor/dmv Form 573 - Marketer Refund

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Marketer Refund
Name & Address:
License Number:
Check here if this is an amended report
Mail
Remittance Center
Refund
PO BOX 5055
Form To:
Sioux Falls, SD 57117-5055
Check if final refund and license is to be cancelled
Claim Period From
to
Report in Whole Gross Gallons Only
Refundable Sales
Column A
Column B
Column C
Column D
Column E
Undyed Diesel
Jet
Gasoline
Gasohol
AVGAS
Fuel
Fuel
1
Gallons of Motor Fuel and Special Fuel sold in bulk to a location on a
licensed Indian school’s premises. (The school must be licensed by the
Department of Revenue & Regulation to purchase fuel exempt from state taxation.
List school name and license numbers below.)
School Name
Indian School License No.
a
a
b
School Name
Indian School License No.
b
c
School Name
Indian School License No.
c
d
School Name
Indian School License No.
d
2
Total gallons of motor fuel and special fuel sold in bulk
to a location on a licensed Indian school’s premises – Add
2
Lines 1a, 1b , 1c, and 1d
3
Total gallons lost in accordance with Section 137 –
Attach completed affidavit and required documents
3
to support this claim
4
Total gallons sold to the U.S. Government – Attach
4
Uniform Schedule of Disbursements - Type 8
5
Total gallons of taxed undyed diesel fuel dispensed into
separate reefer storage for refrigeration use only –
5
Complete Reefer Storage Diesel Worksheet on page 2
REFUND CALCULATION
6
6
Subtotal all gallons – Add lines 2, 3, 4 and 5
7
7
Tax rates
X $0.22
X $0.20
X $ 0.06
X $ 0.22
X $ 0.04
8
8
Total taxes eligible for refund – Multiply line 6 by line 7
$
$
$
$
$
9
9
Total Refund Claim amount - Add column A through E
on Line 8
9
$
I declare and affirm under the penalty of perjury that this report has been examined by me, and to the best of my knowledge and belief is in all things true and correct.
Signature
Title
Date
DOR/DMV FORM 573 (3/97)
Note: Refunds are limited to a period within 15 months of transaction date

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