Form Ft-504 - Claim For Refund Of Taxes Paid On Fuel By A Government Entity Page 3
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4Schedule B ‑ Diesel Motor Fuel Purchases
FT‑504 (9/11) Page 3 of 4
(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)
15 Total gallons purchased
........
(enter here and on lines 2, 5, and 8, Column A)
16 Total excise tax paid/refund claimed
........................
(enter here and on line 2, Column B)
17 Total petroleum business tax paid/refund claimed
...........................
(enter here and on line 5, Column B)
18 Total state and local sales tax paid/refund claimed
......................................................
(enter here and on line 8, Column B)
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