Form Boe-770-Dv (S1f) - Diesel Fuel Ultimate Vendor Report/claim For Refund
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6BOE-770-DV (S1F) REV. 9 (4-13)
STATE OF CALIFORNIA
BOARD OF EQUALIZATION
DIESEL FUEL ULTIMATE VENDOR REPORT/CLAIM FOR REFUND
BOE USE ONLY
RA-B/A
AUD
REG
CLAIM PERIOD
RR-QS
FILE
REF
YOUR ACCOUNT NO.
[
]
FOID
EFF
BOARD OF EQUALIZATION
SPECIAL TAXES AND FEES
PO BOX 942879
SACRAMENTO CA 94279-2050
READ INSTRUCTIONS
BEFORE PREPARING
As an ultimate vendor of diesel fuel in California, you are required to file this report listing your diesel fuel transactions for the
period stated above. This form is also used for filing a claim for refund of tax paid on undyed diesel fuel. Where required to
support your report/claim, you must submit completed Schedules 1A, 2A, 12A through 12C, and 13A through 13J with your
claim. All transactions supporting the amount claimed must be reported on BOE-810-FTG, Receipt Schedule, or BOE-810-FTF,
Disbursement Schedule.
Note: Do not include on this form sales listed on previously filed claims for refund (BOE-770-DV or BOE-770-DVW). If you
qualify to claim ultimate vendor sales on a weekly basis (BOE-770-DVW), any exempt sales for the last week of the period or
claimed at a prior tax rate must be claimed on this form.
REPORT WHOLE
GALLONS ONLY
(A)
(B)
Diesel Fuel at
Diesel Fuel at
Current Rate
Prior Rate
1. Gallons of tax-paid diesel fuel claimed for refund of tax (enter from Refund
Computation Worksheet section A, line 7, columns A and B)
2. Rates of tax per gallon
$
$
3. Subtotal of refund amount (multiply line 1 by line 2 for columns A and B)
$
$
4. Amount of refund claimed (add columns A and B of line 3)
$
CERTIFICATION
I hereby consent to disclose and authorize the Board of Equalization (BOE) to release, as necessary, certain otherwise confidential
transaction information regarding volumes, invoice numbers, bills-of-lading, locations, dates, or method of delivery of reportable
products to any person identified by me in this return as being involved in a reported transaction for the sole purpose of verifying
the accuracy of the reportable product transaction information concerning my transactions with such person as reported in this
return.
I, the undersigned, certify that, to the best of my knowledge, all information on this report/claim and any accompanying
documents is true, correct, and complete. I further certify that the diesel fuel covered by this claim did not show any visible
evidence of dye and, further, that the diesel fuel tax was not included in the sales price of the diesel fuel covered by this claim and
was not collected from the purchasers. In addition, I certify that I have in my possession valid exemption certificates from train
operators for transactions covered by this claim and that, to the best of my knowledge, all the information on the certificates is
true and correct.
SIGNATURE
DATE
TELEPHONE
(
)
PRINT NAME AND TITLE
EMAIL ADDRESS
CONTINUED
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