Form Boe-770-Dz - Claim For Refund On Nontaxable Sales And Exports Of Diesel Fuel

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BOE-770-DZ (S1) REV. 5 (4-13)
STATE OF CALIFORNIA
BOARD OF EQUALIZATION
CLAIM FOR REFUND ON NONTAXABLE SALES AND EXPORTS OF DIESEL FUEL
BOE USE ONLY
RA-B/A
AUD
REG
CLAIM PERIOD
/
/
/
/
THROUGH
RR-QS
FILE
REF
YOUR ACCOUNT NO.
EFF
BOARD OF EQUALIZATION
SPECIAL TAXES AND FEES
PO BOX 942879
SACRAMENTO CA 94279-2O5O
READ INSTRUCTIONS
BEFORE PREPARING
You may use this form to file a claim for refund of tax paid on undyed diesel fuel exported for use outside the state, sold to the
U.S. Government, sold to train operators for use in a diesel-powered train or for other off-highway use, or used in your
operations for purposes other than propelling vehicles on the highway of this state.
Enter the beginning and ending dates of the period covered by this claim as mm/dd/yy in the box above.
Where required to support your claim, you must submit completed Schedules 1A, 2A, 12A through 12C, 13A, 13C, 13G, and
13J with your claim. All transactions supporting the amount claimed must be reported on BOE-810-FTG, Receipt Schedule or
BOE-810-FTF, Disbursement Schedule.
REPORT WHOLE
GALLONS ONLY
(A)
(B)
Diesel Fuel at
Diesel Fuel at
Current Rate
Prior Rate
1. Gallons of tax-paid diesel fuel claimed for refund of tax (enter from Refund
Computation Worksheet section A, line 5, columns A and B)
2. Rates of tax per gallon
$
$
3. Subtotal of refund amount (multiply line 1 and line 2 for columns A and B)
$
$
$
4. Amount of refund claimed (add columns A and B of line 3)
CERTIFICATION
I hereby consent to disclose and authorize the Board of Equalization (BOE) to release, as necessary, certain otherwise confidential
transaction information regarding volumes, invoice numbers, bills-of-lading, locations, dates, or method of delivery of reportable
products to any person identified by me in this return as being involved in a reported transaction for the sole purpose of verifying
the accuracy of the reportable product transaction information concerning my transactions with such person as reported in this
return.
I, the undersigned, certify that, to the best of my knowledge, all information on this claim and any accompanying documents is
true, correct, and complete. I further certify that the diesel fuel covered by this claim did not show any visible evidence of dye and,
further, that the diesel fuel tax was not included in the sales price of the diesel fuel covered by this claim and was not collected
from the purchasers. In addition, I certify that I have in my possession valid exemption certificates from train operators for
transactions covered by this claim and that, to the best of my knowledge, all the information on the certificates is true and correct.
SIGNATURE
EMAIL ADDRESS
PRINT NAME AND TITLE
TELEPHONE NUMBER
DATE
(
)
CLEAR
PRINT

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