Form Pet 377 - Exporter Tax Return And Claim For Refund

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TENNESSEE DEPARTMENT OF REVENUE

EXPORTER TAX RETURN & CLAIM FOR REFUND

Account No.

SSN or FEIN

Filing Period

PET

Beginning:

Location Address

377

Ending:

}

If this is an AMENDED RETURN,

please check the box at right

Due Date

}

If this is a CLAIM FOR REFUND,

please check the box at right

Make your check payable to the Tennessee De-

partment of Revenue for the amount shown on Line 15

and mail to:

Tennessee Department of Revenue

Andrew Jackson State Office Bldg.

500 Deaderick Street

Nashville, TN 37242

GASOLINE

DIESEL

KEROSENE

JET FUEL

AV GAS

TOTAL

EXPORT GALLONS

DYED

UNDYED

1. Destination state tax

COLUMN A

COLUMN B

COLUMN C

COLUMN D

COLUMN E

COLUMN F

COLUMN G

paid gallons

(net of diversions) .........

______________

____________

______________

___________

_______________

2. Tax free gallons

(see instructions) .........

______________

____________

______________

___________

_______________

3. Diversions into

Tennessee ....................

______________

____________

______________

___________

_______________

4. Tennessee tax

paid gallons ...................

______________

____________

______________

___________

_______________

5. Diversions from

Tennessee ....................

______________

____________

______________

___________

_______________

6. Total gallons exported

(Total of lines 4 and 5) ______________

____________

______________

___________

_______________

REFUND COLUMN A

TAX COLUMN B

7. Gasoline privilege tax .................. Line 6-A multiplied by $0.196917

___________________

Line 3-A multiplied by $0.20 ....

___________________

8. Diesel use tax .............................. Line 6-C multiplied by $0.167379 . ___________________

Line 3-C multiplied by $0.17 .....

___________________

9. Special privilege tax .................... Line 6-G multiplied by $0.0095 .... ___________________

Line 3-G multiplied by $0.01 ....

___________________

10. Environmental assurance fee ..... Line 6-G multiplied by $0.004 ....... ___________________

Line 3-G multiplied by $0.004 ..

___________________

11. Totals ........................................... Credit - add lines in Refund Column ___________________

Tax - add lines in Tax Column .

___________________

12. Enter outstanding credit amount from previous Department of Revenue notice(s) ........................................................................

______________________

{

13. Penalty

......

______________________

If filed LATE, compute penalty at 5% of the tax (Line 11B minus Line 12 and 11A) for each 1 to 30 DAY PERIOD or portion thereof for which TAX IS

DELINQUENT (Total penalty NOT TO EXCEED 25%.) Minimum penalty is $15 regardless of the amount of tax due or whether there is any tax due.

14. Interest (Line 11B minus Line 12 and 11A multiplied by

% per annum on taxes unpaid by the due date) ...........................

______________________

15. TOTAL REMITTANCE AMOUNT (Total of lines 11B, 13, and 14; subtract line 12 and 11A if applicable) .......................................

______________________

16. Overpayment - If you are due a refund, please indicate the amount here .....................................................................................

______________________

Under penalties of perjury, I declare that I have examined this report, and

to the best of my knowledge and belief, it is true, correct, and complete.

FOR OFFICE

Date

Taxpayer's Signature

USE ONLY

Signature of Preparer other than Taxpayer

Date

Tax Preparer's Address

Phone Number

RV-R0009701