Form 84ag - Nebraska Ag Use Motor Fuels Tax Refund Claim

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FORM

Nebraska Ag Use Motor Fuels Tax Refund Claim

84AG

Social Security Number or FEIN

Period Covered by this Claim

NAME AND ADDRESS OF CLAIMANT

Beginning ____________________,20_____ Ending ____________________, 20_____

Name

Contact Person

Phone Number

Street Address

Email Address

City

State

Zip Code

Mailing Address of Claimant (If Different)

City

State

Zip Code

Description of Operations

1 Total number of acres

2 Type of crops

3 Number and type of livestock

Type of Equipment in Which Fuel Was Used

Equipment

Make and Model

Is it

(for example, tractor, combine,

(for example, John Deere 7630,

Licensed?

Fuel Used

bobcat, loader)

Ford 8N, Caterpillar 428)

Horsepower

Year

(Yes or No)

(Gasoline or Diesel?)

Fuel Purchases, Usage, and Storage Information (Answer completely.)

Was the fuel purchased at a retail station and placed directly into unlicensed equipment?

YES Purchase invoices must indicate which equipment the fuel was placed into.

Was the fuel placed into a bulk storage tank (portable or stationary) upon purchase?

YES What is the size and location of the storage tanks?

Are both licensed vehicles and unlicensed equipment fueled from these storage tanks?

What controls are used to ensure the fuel is used exclusively for unlicensed equipment?

YES Include withdrawal logs for all use.

Refund Calculation (Attach supporting documentation - see instructions.)

Total

Reduced Refund

For Dept. of Revenue

Product

Gallons

Rate

Amount

Use Only

Approved

Gasoline, Gasohol, or Ethanol*

.0 X

= $

.00

*If the tax paid on fuel claimed is less than $25 within a calendar year, you are not eligible for a refund.

Approved

Undyed Diesel, Undyed Biodiesel, or

Undyed Biodiesel Blends*

.0 X

= $

.00

*If the tax paid on fuel claimed is less than $25 within a calendar year, you are not eligible for a refund.

Under penalties of law, I declare that I have examined this claim and to the best of my knowledge and belief, it is correct and complete. I

further declare that none of this fuel claimed for refund was used in a licensed motor vehicle. I also declare that payment of this claim has not been

previously made by the State, and records supporting this claim are subject to audit for a period of three years from the date the claim was filed.

sign

here

Authorized Signature

Phone Number

Signature of Preparer Other Than Taxpayer

Phone Number

Title

Date

Address

Email Address

FOR MOTOR FUELS DIVISION USE ONLY