Form 0841 V1 - Affidavit Of Loss Of Taxable Fuel
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SD EForm - 0841
V1
Affidavit of Loss of Taxable Fuel
Reference SDCL 10-47B-137
Explanation
Any person or business licensed in the sale of fuels may collect a refund of fuel taxes paid on fuel lost by leakage or theft, or
fuel lost or destroyed by fire, flood, tornado, windstorm or explosion. For a refund of taxes on fuel lost by leakage or theft, the
total gallons lost must exceed 500 gallons. For a refund of taxes on fuel lost or destroyed by fire, flood, tornado, windstorm or
explosion, the total gallons must exceed 100 gallons.
All claims must be filed with the Department of Revenue within 30 days after the loss is discovered.
Attach this completed affidavit to the Marketer Refund Form. Be sure that you have completed Line 3 of the form.
Claimant Information
Claimant Name
License Number
Address
Phone Number
Loss Information
Casualty Loss Caused By – Check One
Fire
Lightning
Flood
Tornado
Windstorm
Explosion
Other (Explain):
_____________
Note: Casualty loss must exceed 100 gallons. Attach copies of insurance report.
Loss Form – Check One
Theft
Tank Leakage
Note: Loss by theft or leakage must exceed 500 gallons. If fuel is lost by theft, attach copies of police and insurance reports.
Type of product Lost
Gallons Lost
Tax Rate
Claim Amount
X
=
$
$
0.00
Date of Loss
Location of Loss
Explanation of circumstances surrounding loss
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. I understand that upon request, my books and records will be made available for inspection by the Department
I also understand that if the loss was not reported to the Department of Revenue by telegram, registered or certified
mail within 10 days of the discovery of the loss, I am not entitled to a refund of any tax paid on the claimed fuel.
Signature
Title
Date
Notarization
Subscribed and sworn before me this __________ day
of _______________________, 20_______.
Affix Seal Here
________________________________________
Notary Public
My commission expires on ________________________
1.
PRINT FOR MAILING
CLEAR FORM
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Parent category: Financial