Form Ref-1000 - Consolidated Application For Fuel Tax Refund Page 3
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6Section VI: Proportional Use Exemption Refund Only
(Please list vehicles consuming gasoline and special fuel on separate lines)
1
2
3
4
5
6
7
Enter the
Number
Liability Period
Eligible
Eligible
Exempt
Proportional
Type
of
Miles
Gallons
Percentage
Use Exempt Gallons
of Vehicle
Vehicles
Traveled
Consumed
Col. 5 x Col. 6
(See Instructions)
(see chart
Use Whole
on page 3 of
Gallons
Beginning
Ending
instructions)
Date
Date
Gasoline
Special Fuel
When form is completed, please return to: Indiana Department of Revenue
Carry to
Carry to
Special Tax Section
Section II
Section II
P. O. Box 1971
Line 7A
Line 7B
Indianapolis, IN 46206-1971
A.
B.
Total Gallons
Section VII: Signature/Authorization
This application must be signed by the taxpayer or authorized agent before it will be accepted by the department (IC 6-6-1.1-904.1 and
IC 6-6-2.5-32).
Applicant agrees, under penalty of perjury, that the information given on this form is, to the best of their knowledge, true, accurate, and
complete. This form must be signed by an owner, a partner, or a corporate offi cer or by an authorized agent. If signed by an authorized
agent, a properly completed power of attorney must be attached to this form.
Taxpayer or Authorized Agent _______________________________________________ Title ______________________________
Type or Print
Signature ______________________________________________________________________ Date Signed ________________
Phone Number __________________ Fax Number ____________________ Email Address ______________________________
□
□
I authorize the department to discuss my return with my tax preparer.
Yes
No
□
□
□
Paid Preparer’s Name
Federal ID Number
PTIN OR
Social Security Number
Address
Preparer’s daytime telephone number
City
Preparer’s Signature
State
ZIP Code
Date
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