Schedule 5 (Form 8849) - Section 4081(E) Claims
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1
2Schedule 5
Section 4081(e) Claims
(Form 8849)
OMB No. 1545-1420
(Rev. January 2006)
Attach to Form 8849. Do not file with any other schedule.
Department of the Treasury
Internal Revenue Service
Name as shown on Form 8849
EIN
Total refund (see instructions)
$
Claimant’s registration number
Part I
Claim for Refund of Second Tax. Caution. Claims are made on Schedule 5 by the person that has
filed Form 720 reporting and paying the tax claimed.
Type of fuel
(a)
(b)
Amount of refund
CRN
$
1
Gasoline
362
2
Aviation gasoline
324
3
Diesel fuel
360
4
Kerosene
346
5
Diesel-water fuel emulsion
309
6
Dyed diesel fuel, dyed kerosene, and other exempt removals
303
7
Kerosene for use in aviation
369
8
Kerosene for use in commercial aviation (other than foreign trade)
355
Part II
Supporting Information Required. See instructions. If more space is needed, attach separate sheets.
Claimant certifies that the amount of the second tax has not been included in the price of the fuel, and has not been
collected from the purchaser. Claimant has attached a copy of the First Taxpayer’s Report, and if applicable, a copy
of the Statement of Subsequent Seller.
(c) Type of fuel
(d)
(e)
(f)
Enter line number from
Date second tax liability incurred
Gallons of fuel claimed
Amount of second tax paid
Part I.
Use MMDDYYYY format.
$
For Privacy Act and Paperwork Reduction Act Notice, see Form 8849 instructions.
Cat. No. 27453B
Schedule 5 (Form 8849) (Rev. 1-2006)
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