Form Ft-504 - Claim For Refund Of Taxes Paid On Fuel By A Government Entity Page 2
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4Schedule A ‑ Motor Fuel Purchases
Page 2 of 4 FT‑504 (9/11)
(Attach additional sheets if necessary.)
Date of
Seller’s information
Invoice
Number of
Excise
Petroleum business
Sales
purchase
number
gallons
tax paid
tax paid
tax paid
Name
City
County
(mm/dd/yy)
11 Total gallons purchased
........
(enter here and on lines 1, 4, and 7, Column A)
12 Total excise tax paid/refund claimed
........................
(enter here and on line 1, Column B)
13 Total petroleum business tax paid/refund claimed
...........................
(enter here and on line 4, Column B)
14 Total state and local sales tax paid/refund claimed
......................................................
(enter here and on line 7, Column B)
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