Form 130 - Oklahoma Tax Commission Application For Refund Of Motor Fuel Tax Gasoline And Undyed Diesel Only - 2013

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Form 130
Revised 2-2013
Oklahoma Tax Commission
Application for Refund of Motor Fuel Tax
Gasoline and Undyed Diesel Only
Claimantʼs Name (Please Print)
FEI or Social Security Number
Address
City, State, ZIP Code
Telephone Number (Daytime)
Type of Business or if Agriculture Include Permit Number
Bank Routing Number
Bank Account Number
Checking
Savings
No Checking or Savings Account (See certification below)
By checking the box I certify that, as an individual, I DO NOT have a checking or savings account at a bank or financial institution. A check will be
mailed to the address on the refund request.
Check Non-Tagged Agriculture or Off-Highway Equipment Using Exempt Fuel
Tractor
Combine
Irrigation Unit
Construction Equipment
Oilfield Equipment
Other Off-Highway Equipment
Purchases
Note: Fuel used in over-the-road vehicles utilized for agriculture purposes is not exempt
and cannot be claimed for refund (i.e. pickups, trucks, cars,RVs, etc.)
(1) Indian Tribal Members Use
(2) Agriculture Use
(3) Diesel Non-Highway
(4) Dual Purpose Use
*Indicate appropriate
refund code number
(5) Unlicensed Exporter
(6) Tank Wagon Exporter
(7) Unexpected Loss
(8) Other
for each purchase
(9) Garbage or Solid Waste Disposal
Retail
Date of
*Refund Code
Gallons of
Gallons of
Location of Supplier
Name of Supplier
Price Per
Purchase
Number
Gasoline
Diesel
Gallon
1. Total Exempt Gallons of Gasoline and/or Undyed Diesel Purchased .....................................................................
X
X
2. Tax Rate (The rate for agriculture use of gasoline is .1392, Aviation is .1592, otherwise the rate is .16 ................
$.13
$
$
3. Refund Claimed (Line 1 x Line 2) ..........................................................................................................................
Under penalty of perjury, I declare the information contained in this report is true, correct, and complete to the best of my knowledge and belief.
All purchases claimed above have been paid.
Date
Claimant’s Signature
Applicant must maintain documentation to support the claim for a period of three (3) years. Only completed claim forms will be considered.
Refund Code must be given for claim to be processed. Please see complete instructions on the back of this form.
Mail Completed Claim Form To:
Oklahoma Tax Commission
Account Maintenance Division/Credits and Refunds Section
2501 Lincoln Boulevard
Oklahoma City, OK 73194

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