Claim For Diesel Fuel Tax Refund - Alabama Department Of Revenue
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1
2A
D
R
LABAMA
EPARTMENT OF
EVENUE
B
& L
T
D
USINESS
ICENSE
AX
IVISION
RESET
M
F
S
OTOR
UELS
ECTION
P.O. Box 327540 • Montgomery, AL 36132-7540 • (334) 242-9608
Claim For Diesel Fuel Tax Refund
SUBT: DR
Rev. 8/12
(NO GASOLINE ALLOWED)
NAME
QUARTER ENDING
ADDRESS
FEIN OR SSN
CITY
STATE
ZIP CODE
PHONE NUMBER
(
)
EMAIL ADDRESS
CONTACT PERSON
Check Here
If New Address
INDICATE TYPE OF OFF-ROAD BUSINESS:
Agricultural
Logging
Refrigeration Units
Construction
Mining
Other ______________________________________________
Attach a list of all off-road vehicles or equipment which you own/rent. NOTE: Vehicles or equipment may not be designated as both
on-road and off-road.
TAX REFUND COMPUTATION:
1
1. Total gallons of undyed diesel fuel purchased during the quarter. . . . . . .
2. Total gallons of undyed diesel fuel purchased which was used
2
off-road for which a refund is claimed.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
X
$ 0.19
3
3. Rate of tax refund. (Effective Oct. 1, 2004). . . . . . . . . . . . . . . . . . . . . . . . . .
$
4
4. Amount of refund claimed. (Line 2 multiplied by line 3.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
SALES TAX COMPUTATION:
$
5
5. Cost of Fuel Refunded . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
X
$ 0.04
6
6. State Sales Tax Rate (4% of Cost of Fuel.) . . . . . . . . . . . . . . . . . . . . . . . . .
$
7
7. Total Sales Tax Due. (Line 5 multiplied by line 6.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
8
8. Net Refund Due (Line 4 minus line 7.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Sales Tax Remitted to Alabama Department of Revenue:
Yes (Account No. ________________________ )
No
I declare under penalties of perjury that this claim has been examined by me and to the best of my knowledge and belief is true and cor-
rect, and that the number of gallons shown in Item 2 does not exceed the total number of gallons of undyed diesel fuel on which I am
legally entitled, under the laws of the State of Alabama, to a refund of the State excise tax paid under the provisions of Section 40-17-
325, Code of Alabama 1975.
Signature: _________________________________________________________________ Date: ____________________________
Title or Position: ______________________________________________________________________________________________
Any applicant for the refund of taxes who willfully files an inaccurate petition or false claim for a refund shall be subject to a
penalty of 100% of the refund claimed, plus interest. Records to clearly substantiate this petition must be maintained by the
applicant for a period of six years and must be made available to the Alabama Department of Revenue or its authorized agents
upon request. *FAILURE TO SUBMIT INVOICES ACCEPTABLE TO THE ALABAMA DEPARTMENT OF REVENUE OR TO COM-
PLETE ALL THE QUESTIONS WILL RESULT IN THIS CLAIM BEING RETURNED TO YOU.
Contact the Alabama Department of Agriculture & Industries, Petroleum Commodities Section, P.O. Box 3336, Montgomery, AL
36109-0336 or (334) 240-7127 concerning the applicable inspection fee.
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