Form 4404 - Refund Request For Motor Fuel End Users

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Michigan Department of Treasury
4404 (Rev. 7-09)
Refund Request for Motor Fuel End Users
Qualifying Products: End Users of Undyed Diesel Fuel containing at least 5% biodiesel and gasoline containing at least 70%
ethanol.
Issued under authority of P.A. 403 of 2000, as amended. Filing is voluntary.
TAXPAYER INFORMATION
Forms must be postmarked by November 29, 2006.
Company Name
FEIN
Contact Person Name
Telephone Number
Fax Number
E-mail Address
Undyed Biodiesel
Ethanol Blends
INVENTORY REPORT
(B05 or higher)
(E70 - E99)
1. Gallons of diesel fuel containing at least 5% biodiesel (including 100% biodiesel) and gasoline
containing at least 70% ethanol (excluding 100% ethanol) in bulk storage as of August 31, 2006.
Copies of invoices must be submitted.
3,000
3,000
2. End users must deduct 3,000 gallons.
3. Refundable gallons: Subtract line 2 from line 1. If less than zero, enter 0 and do not proceed.
.03
.07
4. Refund Rate.
5. Refund Request. Multiply line 3 by line 4.
CERTIFICATION
CERTIFICATION
I authorize Treasury to discuss my return with my preparer.
Yes
No
Authorized Signature
Signature of Preparer
Printed Name
Printed Name
Date
Telephone Number
Preparer's FEIN
Telephone Number
Title
Address
Mail Refund Request to (must be postmarked by November 29, 2006):
Michigan Department of Treasury
Special Taxes Division
P.O. Box 30474
Lansing, MI 48909-7974

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