Form Ga-110lmp - Claim For Refund
Download a blank fillable Form Ga-110lmp - Claim For Refund in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Ga-110lmp - Claim For Refund with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1Form
Indiana Department of Revenue
GA-110LMP
Claim for Refund
State Form 24721
Sales Tax on Gasoline, Gasohol, & Special Fuel
(R4 / 12-15)
Dispensed Through Stationary Metered Pumps in Indiana
Name of Taxpayer
Taxpayer Identification Number (TID)
Address
Social Security or Federal ID Number
City
State
ZIP Code
US DOT Number
Describe exempt use of gasoline, gasohol, or special fuel and period for which you are filing a refund. Attach additional sheets (if necessary):
Period
Fuel Type
Exempt Use
Note: As of July 1, 2014, gasoline and gasohol are no longer subject to sales tax and should not be claimed on Form GA-110LMP for
periods after June 30, 2014. Refund claims for gasoline use tax for periods beginning July 1, 2014, should be claimed on Form GA-
110L.
Tax rates for gasoline, gasohol, or special fuel (diesel), as listed below, can be found in Departmental Notice #12 on our website at
Special fuels include diesel, liquid natural gas (LNG), and compressed natural gas (CNG).
Column A
Column B
Column C
Gasoline
Gasohol
Special Fuel
1. Total gallons purchased for exempt use per receipts (use whole
gallons)
gallons
gallons
gallons
2. Total purchase price
3. Combined state and federal rate (From Departmental Notice #12)
.364
.364
.404
4. Total state and federal excise tax included in sales (multiply Line 1 by
Line 3)
5. Taxable amount (subtract Line 4 from Line 2)
6. Total sales tax paid on exempt gallons for exempt purposes (multiply
Line 5 by .0654)
7. Total Requested Refund Amount
Add Columns A, B, and C from Line 6
The person or organization representative signing this application hereby certifies that sales tax has been paid on the purchase of
gasoline, gasohol, or special fuel through a stationary metered pump as shown by attached receipts, such fuel has been used for
a purpose which is exempted in Section IC 6-2.5 of the State Gross Retail Sales Act, and no other claim for refund has been filed
on purchases shown on the attached receipts. I further understand that this refund may be applied to any liability which I currently
have outstanding. Under penalties of perjury, I declare that the information given on this form is, to the best of my knowledge, true,
accurate, and complete.
Signature of Applicant ______________________________________________ Telephone Number _______________________
Printed Name __________________________________________ Email Address ______________________________________
Title ___________________________________________________________________ Date ___________________________
For assistance:
Mail to: Indiana Department of Revenue
Call: (317) 615-2552
Special Tax Section
E-mail: fetax@dor.in.gov.
P.O. Box 1971
Indianapolis, IN 46206-1971
________________________________________________________________
________________________________
Auditor/Tax Analyst Originating Refund
Date
________________________________________________________________
________________________________
Supervisor/Administrator
Date
________________________________________________________________
________________________________
Commissioner/Appointee
Date
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial