Form R-5377 - Registration Application For Diesel Fuels Refund
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R-5377 (11/07)
Registration Application for
Diesel Fuels Refund
Mail to:
Louisiana Department of Revenue
Taxpayer Services Division
Excise Tax Section
P.O. Box 66362
Baton Rouge, LA 70896-6362
(225) 219-7656 (225) 219-2114 (TDD)
Please print or type.
Legal Business or Corporation Name
Applicant’s FEIN/SSN
Date
Trade Name or DBA (if different from Business Name)
Contact Person
Applicant’s Physical Location (do not list P.O. Box)
City
State
ZIP
Mailing Address (if different from above)
City
State
ZIP
Telephone Number
Fax Number
E-Mail Address
(
)
LA Sales Tax Number
LA Corporation Tax Number
LA Motor Fuel Tax Number
Please give a brief description of your business and intended use of fuel:
1. How many highway-licensed vehicles do you have?
2. How many off-road vehicles/equipment do you have?
3. Provide detailed information for all vehicles/equipment on the back of this application. (This information is required.)
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4. On what type fuel do you intend to file a refund claim?
Undyed Kerosene
Undyed Diesel
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5. Do you store bulk fuel on your property?
Yes
No
If yes, provide a detail explanation.
6. Do you pick up bulk fuel or is it delivered to you?
7. Provide name and address of supplier from whom you purchase bulk fuel.
FOR OFFICE USE ONLY
Name (Please print)
Signature
Account Number
By ________________________________
Date ____________
Date
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Parent category: Financial