Form 0842 V1- Affidavit For Bad Debt Loss-Marketer
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Affidavit for Bad Debt Loss — Marketer
HELP
Reference SDCL 10-47B-134
SD EForm - 0842
V1
Explanation
Any licensed marketer may apply for a refund of fuel taxes paid on gasoline, gasohol, undyed diesel fuel or LPG sold to a
customer whose account is found to be worthless. (An account is considered worthless when it has been claimed as
uncollectible and deducted as an expense on the marketer’s federal income tax return.) A marketer may collect this refund for
a specific customer only once every three years. After submitting this affidavit, the marketer becomes responsible for fuel
taxes due on future sales to the same customer.
Once the Department of Revenue receives this affidavit, it will notify all licensed suppliers and marketers that:
•
the customer has been delinquent in the payment of fuel taxes
•
the customer is no longer entitled to delay payment of taxes to any supplier for the following three years
•
no further tax refunds will be paid to suppliers or marketers who sell fuel to this customer for a three-year period
To qualify for this refund, the marketer must provide the Department with sufficient written evidence to justify the claim and to
enable the Department to collect payment from the delinquent customer.
Marketer Information
Marketer Name
License Number
Address
Phone Number
Claim Information
—
Attach copies of all documents identified below and a copy of your federal income tax return
Bad debts claimed on this schedule are deducted as an
expense on my federal income tax return for the tax period from
to
Debtor
Document
Selling
Gallons
Fuel
Tax Rate
Total Tax
Name & Address
No.
Date
Sold
Type
Charged
Claimed
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
Total Tax Claimed for Refund
0.00
Signature
I declare and affirm under the penalty of perjury that this report has been examined by me, and to the best of my knowledge
and belief is in all things true and correct.
Signature
Title
Date
1.
PRINT FOR MAILING
CLEAR FORM
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