Form Pet 375 - Wholesaler Application For Refund Of Tax On Motor Fuels

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PET

375

TENNESSEE DEPARTMENT OF REVENUE

WHOLESALER APPLICATION FOR REFUND OF TAX ON MOTOR FUELS

Name of Claimant __________________________________________

SSN/FEIN ____________________________________

Location Address __________________________________________

Account No. ___________________________________

City, State, ZIP _____________________________________________

Claim Period:

Beginning ______________________

Mailing Address ___________________________________________

Ending ________________________

City, State, ZIP _____________________________________________

Date of Claim _________________________________

}

If this is an amended CLAIM FOR RE-

FUND, please check the box at right

Part A. Limited User and Prepaid User Sales

Undyed Diesel

Name of Limited User or Prepaid User

Account No.

No. Of Gallons Sold

__________________________________________________

____________

____________________________

__________________________________________________

____________

____________________________

__________________________________________________

____________

____________________________

__________________________________________________

____________

____________________________

__________________________________________________

____________

____________________________

__________________________________________________

____________

____________________________

__________________________________________________

____________

____________________________

__________________________________________________

____________

____________________________

__________________________________________________

____________

____________________________

__________________________________________________

____________

____________________________

Total (Enter on Line 2 in Computation Section below)

____________________________

Part B. Is this a claim related to dye contamination of diesel fuel or a casualty loss ? (Yes/No) ___________

If yes, complete Part B schedule on the back of this form.

Gallons from

Computation of Refund Due

Part A or Part B

1. Gasoline Tax

$.196917 multiplied by

_______________

............................ (1) $ _________________

2. Diesel Tax

$.167379 multiplied by

_______________

............................ (2) $ _________________

3. Total Refund Due (add lines 1, and 2) ......................................................................................... (3) $ _________________

OATH OF TAXPAYER

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

and complete.

Name ___________________________________________

Title ___________________________________________

(Signature of Taxpayer, Officer, or Authorized Representative)

FOR OFFICE USE ONLY

CHECKED BY

DATE

APPROVED

REASON FOR REDUCTION

REFUND NO.