Form 8849 - Claim For Refund Of Excise Taxes
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48849
Claim for Refund of Excise Taxes
Form
OMB No. 1545-1420
(Rev. August 2014)
Department of the Treasury
▶
Information about Form 8849 and its instructions is at
Internal Revenue Service
Print clearly. Leave a blank box between words.
Name of claimant
Employer identification number (EIN)
Address (number, street, room or suite no.)
Social security number (SSN)
City or town, and state or province. If you have a foreign address, see instructions.
ZIP or foreign postal code
Foreign country, if applicable. Do not abbreviate.
Month claimant’s income tax year ends
Daytime telephone number (optional)
Caution. Do not use Form 8849 to make adjustments to liability reported on Forms 720 for prior quarters or to claim any amounts
that were or will be claimed on Form 720, Schedule C; Form 4136, Credit for Federal Tax Paid on Fuels; Form 2290, Heavy Highway
Vehicle Use Tax Return; or Form 730, Monthly Tax Return for Wagers.
Schedules Attached
Check (
) the appropriate box(es) for the schedule(s) you attach to Form 8849. Only attach the schedules on which you are claiming
✓
a refund. Schedules 2, 3, 5, and 8 cannot be filed with any other schedules on Form 8849. File each of these schedules with a
separate Form 8849.
Schedule 1
Nontaxable Use of Fuels
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Schedule 2
Sales by Registered Ultimate Vendors .
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Schedule 3
Certain Fuel Mixtures and the Alternative Fuel Credit
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Schedule 5
Section 4081(e) Claims .
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Schedule 6
Other Claims
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Schedule 8
Registered Credit Card Issuers
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Under penalties of perjury, I declare (1) that I have examined this claim, including accompanying schedules and statements, and to the best of my
knowledge and belief, it is true, correct, and complete, and (2) that amounts claimed on this form have not been, and will not be, claimed on any
other form. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Sign
Here
Signature and title (if applicable)
Date
Type or print your name below signature.
Print/Type preparer’s name
Preparer’s signature
Date
PTIN
Paid
Check
if
self-employed
Preparer
Firm’s name
▶
Use Only
Firm’s EIN
▶
Phone no.
Firm’s address
▶
8849
For Privacy Act and Paperwork Reduction Act Notice, see instructions.
Form
(Rev. 8-2014)
Cat. No. 20027J
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