Sd Eform-0832 V2 - Affidavit Of Accidental Mixing Of Undyed Fuel With Dyed Fuel
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1SD EForm -
0838
V2
Complete and use the button at the end to print for mailing.
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Affidavit of Accidental
Mixing of Undyed Fuel With Dyed Fuel
Reference SDCL 10-47B-132
Explanation
Any business or person may collect a refund of fuel taxes on undyed fuel that is accidentally mixed with dyed fuel.
However, to qualify for this refund, the amount of undyed fuel accidentally mixed must exceed 500 gallons and the claimant
must notify the Department of Revenue within 5 days of the accidental mixture.
Claimant Information
Claimant Name
License Number (If Applicable)
Address
Phone Number
Attach copies of all fuel invoices related to this accidental mixture.
1 Total gallons of undyed diesel fuel accidentally mixed with dyed diesel fuel – Obtain from sales invoice
1
2 Fuel Tax Rate
2
$0.22
$
3 Total Fuel Tax Due – Multiply Line 1 by Line 2
3
0.00
4 Total Fuel Cost – Obtain from invoice
4
5 Net Fuel Cost – Subtract Line 3 from Line 4
5
$
0.00
6 Sales Tax Due – Multiply amount on Line 5 by $0.04
$
6
0.00
7 Refund Amount – Subtract Line 6 from Line 3
7
$
0.00
Claimant and/or Marketer/Retailer Signature
I/we declare and affirm under the penalty of perjury that __________________ gallons of undyed (taxed) fuel were
accidentally mixed with _________________ gallons of dyed fuel on _____________________, 20_____. I/we
understand that the mixed fuel may be dyed by the Department of Revenue to the specifications set forth by law if deemed
necessary by the Secretary of Revenue. I/we further declare that this dyed fuel will be used for the purpose stated below.
Explain Purpose for Dyed Fuel
Claimant Signature
Title
Date
Marketer/Retailer 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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