Form 84 - Nebraska Non-Ag Use Motor Fuels Tax Refund Claim
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Nebraska Non-Ag Use Motor Fuels Tax Refund Claim
FORM
84
If this claim results from farming or ranching, file
Form
84AG.
Social Security Number or FEIN
Period Covered by this Claim
NAME AND ADDRESS OF CLAIMANT
Beginning ____________________,20_____ Ending ____________________, 20_____
Name
Contact Person
Phone Number
Street Address
Email Address
City
State
Zip Code
Mailing Address of Claimant (If Different)
City
State
Zip Code
Indicate reason for the claim:
The purchase of motor fuels was made by agencies of the federal government.
The motor fuel was used in unlicensed equipment — include equipment list.
The motor fuel was used in refrigeration units.
Gasoline was used as aviation fuel.
There was an accidental contamination of fuel.
Was this fuel withdrawn from a bulk storage tank which was also used to fuel licensed vehicles?
YES
NO
Supporting documentation must be attached, as required (see instructions).
For Dept. of
Less:
Net
Total
Refund
Adjustments
Amount
Revenue
Use Only
Product
Gallons
Rate
Amount
(see instructions)
Claimed
Approved
Gasoline, Gasohol,
or Ethanol*
.0 X
=
$
.00 – $
.00 =
$
.00
$
*If the tax on fuel claimed is less than $25 within a calendar year, you are not eligible for a refund.
Approved
Undyed Diesel,
Undyed Biodiesel, or
Undyed Biodiesel Blends*
.0 X
=
$
.00 – $
.00 =
$
.00
$
*If the tax on fuel claimed is less than $25 within a calendar year, you are not eligible for a refund.
Aviation Gasoline
.0 X
$0.05
=
$
.00
Jet Fuel
.0 X
$0.03
=
$
.00
Approved
Total Aviation Fuels*
.0
$
.00 – $
.00 =
$
.00
$
*If the tax on fuel claimed is less than $25 within a calendar year, you are not eligible for a refund.
Petroleum Release Remedial Action Fee
Motor Vehicle Fuels
.0 X
=
$
.00
$0.009
Other Petroleum Products
.0 X
=
$
.00
$0.003
Approved
Total Fee*
.0
$
.00
$
*If the fee on fuel claimed is less than $10 within a calendar year, you are not eligible for a refund.
Under penalties of law, I declare that I have examined this claim and to the best of my knowledge and belief, it is correct and complete. I further
declare that unless used by an agency of the federal government or by buses for hire, none of this fuel claimed for refund was used in a licensed
motor vehicle. I also declare that payment of this claim has not been previously made by the State and records supporting this claim are subject to
audit for a period of three years from the date the claim was filed.
sign
here
Authorized Signature
Phone Number
Signature of Preparer Other Than Taxpayer
Phone Number
Title
Date
Address
Email Address
Email Address
FOR MOTOR FUELS DIVISION USE ONLY
APPROVED
COMMENTS:
APPROVED AS ADJUSTED
DISAPPROVED
Authorized Signature
Date
Mail this claim, with substantiating documentation to: MOTOR FUELS DIVISION, PO BOX 98904, LINCOLN, NE 68509-8904.
, 800-554-3835, 402-471-5730
RETAIN A COPY FOR YOUR RECORDS.
7-2013
3-194-1975 Rev.
Supersedes 3-194-1975 Rev. 1-2013
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