Form Dr-309660 - Application For Pollutants Tax Refund - 2013
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6DR-309660
Florida Department of Revenue
R. 01/13
Application for Pollutants Tax Refund
Rule 12B-5.150
Florida Administrative Code
Effective 01/13
Mail application to:
Complete Parts 1 through 6 and attach appropriate
Refunds
Handwritten Example
Typed Example
documentation. Type or print clearly. Your refund
0 1 2 3 4 5 6 7 8 9
0123456789
Florida Department of Revenue
application will be rejected if red boxes are not
Use black ink.
PO Box 6490
completed in full.
Tallahassee FL 32314-6490
Name of applicant:
Mailing street address:
Mailing city, state, ZIP:
Location street address:
Location city, state, ZIP:
Business telephone number
Fax number (include area
–
–
–
–
(include area code):
code optional):
Email address:
Part 2
Under penalty of perjury, I declare that I have read this application and the facts stated in it are true.
Sign and date this form.
Signature of applicant/representative:
Date:
Print name:
Title:
–
–
Representative’s phone number:
Part 3
$
,
,
.
Enter amount of refund.
Part 4
Identification number of applicant:
Provide the
Federal employer identification number:
Fuel tax license number:
identification number
under which the tax
–
–
was paid.
Business partner number:
Part 5
/
/
/
/
Enter the period shown
Period
to
on the tax return(s)
M
M
D
D
Y
Y
M
M
D
D
Y
Y
used to report the tax
and/or when it was
/
/
/
/
Paid
to
paid.
M
M
D
D
Y
Y
M
M
D
D
Y
Y
Reasons for this refund (additional sheets may be added):
Part 6
Clarify and speed up your
refund claim by providing
a brief explanation.
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