Form 04-544 - Claim For Refund Motor Fuel Tax - Alaska Department Of Revenue Page 2

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Alaska Department of Revenue
Claim for Refund
Schedule of Invoices
Range of Dates for Fuel Purchased
Name:____________________________________________
From:
/
/
To:
/
/
EIN:
____________________________________________
This schedule is required only if there are more than 10 invoices accompanying this refund claim. Attach original purchase invoices .
Fuel Type: (Check only one box)
65 Gasoline
130 Jet Fuel
124 Gasohol
160 Diesel
125 Aviation Gasoline
Gallons Purchased at
Supplier Name
8 Cents
5 Cents
4.7 Cents
3.2 Cents
2 Cents
Total Gallons
Attach this schedule to your Claim for Refund. Use additional sheets as necessary.
Form 04-544.1 (Rev 04/01)

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