Form Pet 354 - Specialized Equipment Claim For Refund

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PET
354
TENNESSEE DEPARTMENT OF REVENUE
SPECIALIZED EQUIPMENT CLAIM FOR REFUND
1. Name of Claimant __________________________________________
2. SSN/FEIN __________________________________
Location Address __________________________________________
Account No. _________________________________
City, State, ZIP _____________________________________________
3. Date of Claim _______________________________
Mailing Address ___________________________________________
4. Claim Period: _______________________________
Semi-Annual Period Ending
City, State, ZIP _____________________________________________
DIESEL
GASOLINE
DIESEL REFUND
8.
.
.
.
.
.
.
GASOLINE REFUND
9.
.
.
.
.
.
.
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
APPROVAL
Approved Amount $ ______________
__________________________________________
________________________________________
_____________
Director or Designate
Commissioner of Revenue or Designate
Date

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