Form 8849 - Claim For Refund Of Excise Taxes
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48849
Claim for Refund of Excise Taxes
Form
OMB No. 1545-1420
(Rev. January 2009)
Department of the Treasury
Internal Revenue Service
Print clearly. Leave a blank box between words.
Name of claimant
Employer identification number (EIN)
Address (number, street, room or suite no.)
Social security number (SSN)
City and state or province. If you have a foreign address, see page 2.
ZIP code
Foreign country, if applicable. Do not abbreviate.
Month claimant’s income tax year ends
Daytime telephone number (optional)
Caution. Do not use Form 8849 to make adjustments to liability reported on Forms 720 for prior quarters or to claim any amounts
that were or will be claimed on Schedule C (Form 720), Claims, Form 4136, Credit for Federal Tax Paid on Fuels, Form 2290,
Heavy Highway Vehicle Use Tax Return, or Form 730, Monthly Tax Return for Wagers.
Schedules Attached
Check ( ) the appropriate box(es) for the schedule(s) you attach to Form 8849. Only attach the schedules on which you are claiming
a refund. Schedules 2, 3, 5, and 8 cannot be filed with any other schedules on Form 8849. File each of these schedules with a
separate Form 8849.
Schedule 1
Nontaxable Use of Fuels
Schedule 2
Sales by Registered Ultimate Vendors
Schedule 3
Certain Fuel Mixtures and the Alternative Fuel Credit
Schedule 5
Section 4081(e) Claims
Schedule 6
Other Claims
Schedule 8
Registered Credit Card Issuers
Under penalties of perjury, I declare (1) that I have examined this claim, including accompanying schedules and statements, and to the best
of my knowledge and belief, it is true, correct, and complete, and (2) that amounts claimed on this form have not been, and will not be, claimed
on any other form. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Sign
Here
Signature and title (if applicable)
Date
Type or print your name below signature.
Check
Date
Preparer’s SSN or PTIN
Preparer’s
if self-
Paid
signature
employed
Preparer’s
Firm’s name (or
EIN
yours if self-employed),
Use Only
address, and ZIP code
Phone no. (
)
8849
For Privacy Act and Paperwork Reduction Act Notice, see instructions.
Cat. No. 20027J
Form
(Rev. 1-2009)
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