Form Rev-568 - Assignment Of Rights To Liquid Fuels And Fuels Tax Reimbursements

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REV-568 MF (5-13)
ASSIGNMENT OF RIGHTS
TO LIQUID FUELS AND FUELS
Bureau of Motor and Alternative Fuel Taxes
TAX REIMBURSEMENTS
PO BOX 280646
Harrisburg PA 17128-0646
For value received, the undersigned, having authority to execute this assignment, does hereby assign and
transfer to
(NAME OF FUEL SUPPLIER)
(ADDRESS)
all his, her, its or their rights to liquid fuels and fuels tax which may be refunded by the Commonwealth
of Pennsylvania. This assignment is for the period from
MM/DD/YYYY
to
. The undersigned further agrees that he, she, it or they will not file a claim
MM/DD/YYYY
for refund for any liquid fuels and fuels tax that is/are the subject of this assignment.
Dated:
MM/DD/YYYY
(PRINT NAME OF EXEMPT ENTITY)
CORPORATE
SEAL
EIN
(PRINT NAME AUTHORIZING THIS ASSIGNMENT)
PLEASE SIGN AFTER PRINTING FORM
(SIGNATURE)
(TITLE)
STATE OF
)
) SS.
COUNTY OF
)
On this, the
day of
, 20
,
before me
, the undersigned officer,
personally appeared
,
known to me (or satisfactorily proven) to be the person(s) whose name(s) is / are subscribed to the within
instrument, and acknowledged the execution of this assignment for the period and purpose herein contained.
IN WITNESS WHEREOF,
I hereunto set my hand and official seal.
My Commission Expires:
Bureau of Motor and Alternative Fuel Taxes
PRINT FORM
Reset Entire Form
P.O. Box 280646 | Hbg, PA 17128-0646 | 1.800.482.4382 |

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