Form Ref-1000a - Affidavit Of Certifi Cation Of Tax Paid Invoices

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Indiana Department of Revenue
Mail to:
Form REF-1000A
Indiana Department of Revenue
Special Tax Division
State Form 48389
Special Tax Section
(R2 / 5-13)
Affi davit of Certifi cation of Tax Paid Invoices
P.O. Box 1971
Indianapolis, IN 46206-1971
317-615-2552
Name of Seller
DBA
Address
City/Town
State
Zip Code
FEIN Number
Social Security Number
RRMC Number
Business Telephone Number
Email Address (optional)
The attached copies of (number of) _________ invoice(s) showing (name) ________________________________ as
purchaser represent sales of fuel on the dates shown on the invoices by the supplier whose name appears above.
Listed below are the invoice number(s), date(s), and gallonage of these purchases according to our records. (attach addi-
tional sheets if necessary)
Copies of all listed invoices are attached. These records are available for review at:
_______________________________________________________________________________________________
Diesel/
Diesel/
Invoice
Gasoline
Invoice
Gasoline
Number
Date
Gallons
(Select One)
Number
Date
Gallons
(Circle One)
□
□
Diesel
Diesel
□
□
Gasoline
Gasoline
□
□
Diesel
Diesel
□
□
Gasoline
Gasoline
□
□
Diesel
Diesel
□
□
Gasoline
Gasoline
Seller’s Signature ____________________________________
Title _________________________________
STATE OF _____________
)
)
COUNTY OF ____________ ) SS:
Before me the undersigned, a Notary Public for ____________________ County, State of ______________,
personally appeared ________________, and he being fi rst duly sworn by me upon his oath, says that the facts
alleged in the foregoing instrument are true. Signed and sealed this ______ day of _______________, 20 _____.
____________________________________
(Signature) Notary Public
____________________________________
(Printed Name)
County of Residence: ________________________ My Commission Expires: __________________

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