Form R-5330 - Registration For Fuel Tax Refund For Commercial Fishermen
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1R-5330 (07/07)
Registration For Fuel Tax Refund
For Commercial Fishermen
• This form must be completed and submitted to the
Department of Revenue before the applicant may
Louisiana Department of Revenue
purchase fuel subject to tax refund. The applica-
Taxpayer Services Division/Excise Taxes Section
tion is for licensed commercial fi shermen only
P. O. Box 201
and does NOT apply to charter fi shing boats.
Baton Rouge, LA 70821-0201
• A copy of your latest federal income tax return
(225) 219-7656
(225) 219-2114 (TDD)
must accompany this application.
Please Print or Type
Name of Applicant
Date (MM,DD,YYYY)
Physical Address
Mailing Address
City
State
Zip
LA Account ID
FEIN/SSN
Home Telephone Number
Offi ce Telephone Number
Fax Number
Parish of Residence
Boat location
Commercial Fishing License No.
List vessels to be used in your fi shing activities in which refund gasoline will be used.
Name of Boat
LA Registration No.
Make of engine
Horse power
List automotive vehicles used in commercial fi shing activities as well as type of fuel used therein;
G = Gasoline; CD = Clear Diesel.
Make & Model
Year
VIN
License No.
Describe how each vehicle will be used
Circle Fuel Type
G
CD
G
CD
G
CD
G
CD
G
CD
(If space is insufficient, attach schedule)
Signature of applicant
X
Furnish signatures of any other persons authorized to sign refund invoices for the above applicant when fuel is purchased.
Signature
Signature
X
X
FOR OFFICE USE ONLY
Region
Verifi ed By
Date (MM,DD,YYYY)
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Parent category: Financial