Form Pet 353 - Agricultural Purposes Claim For Refund Page 2
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1
214. List below Number, Date and Gallons of each attached invoice.
Invoice No.
Date
Gallons
1.
________________________
____________________________
____________________________
2.
________________________
____________________________
____________________________
3.
________________________
____________________________
____________________________
4.
________________________
____________________________
____________________________
5.
________________________
____________________________
____________________________
6.
________________________
____________________________
____________________________
7.
________________________
____________________________
____________________________
8.
________________________
____________________________
____________________________
9.
________________________
____________________________
____________________________
10.
________________________
____________________________
____________________________
11.
________________________
____________________________
____________________________
12.
________________________
____________________________
____________________________
INSTRUCTIONS
Please follow instructions carefully. Incomplete or improperly completed claims will be returned without action. This could result in denial of claim.
These instructions correspond to the line numbers as they appear on the reverse side of this form.
Line 1
Name and Address. Enter your complete name and mailing address.
Line 2
Location of Farm. Enter the address and county in which your farm is located.
Line 3
Account Number. Enter your account number.
Line 4
Claim Period, Date Filed, and Amount Claimed. Enter the claim period for which the claim is filed. Claims can be filed either semi-
annually or annually. Semi-annual claims may be filed during the following periods: Claim period: January-June; July 1-October 15.
Claim period: July-December; January 1-April 15. Annual claims may be filed January 1-April 15, for the immediate twelve (12) months
preceding the filing period.
Enter the date this claim was completed and filed. Enter the amount claimed after completing the remaining sections of this claim.
Line 5
Distributor. Enter the name and address of your fuel supplier.
Lines 6-12 Complete all questions six (6) through (12). Each question should be self-explanatory.
Line 13
Amount of tax to be refunded. Multiply amount on Line 12 by nineteen cents ($.19) and place amount in space provided. Amount
claimed on semi-annual or annual claims must be at least $25.00.
Line 14
List of invoices. List all invoices which support your claim.
Line 15
Remarks. Enter any comments you have regarding your claim.
Please sign your name in the space provided on the front and mail to the Tennessee Department of Revenue, Andrew Jackson Building, 500
Deaderick Street, Nashville, Tennessee 37242.
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