Form 1822 - South Dakota Motor Fuel Tax Tribal Refund Application
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1SD EForm - 1822
V1
Complete and use the button at the end to print for mailing.
HELP
Motor Fuel Tax Tribal Refund Application - Pourier v. DOR
Mail Claim Form to: South Dakota Department of Revenue
MF-003
Division of Motor Vehicles - Motor Fuel
Revised
01/04
445 E. Capitol Avenue | Pierre, SD 57501-3185 | 605-773-5335
Application Instructions
A tribal member who has purchased motor fuel or special fuel in Indian country may apply for a refund of the fuel tax
paid. To be eligible, the individual must be an enrolled tribal member and have purchased the fuel within the last 15
months on Indian country controlled by their own tribe.
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Fuel Types
Report the Total Number of Gallons for each type of fuel that you claim a refund.
INVOICES OR RECEIPTS MUST BE
ATTACHED TO THIS APPLICATION SUBSTANTIATING YOUR CLAIM, OR ANY OTHER EVIDENCE OF THE TIME,
AMOUNT, AND PLACE OF PURCHASE NECESSARY TO SUBSTANTIATE YOUR CLAIM.
Fuel Type
Quantity of Gallons Purchased
Gasoline
Clear Diesel
Gasohol
(Ethanol Blend)
LPG
Clear Soy Diesel
Avgas
Jet Fuel
E85 & M85
CNG
Other
Total Gallons
0.00
Signature
I declare and affirm under the penalty of perjury that this application has been examined by me, and to the best of my
knowledge and belief, is in all things true and correct.
Signature
Date
NOTE: REFUNDS ARE LIMITED TO A PERIOD WITHIN 15 MONTHS OF THE DATE OF PURCHASE.
PRINT FOR MAILING
CLEAR FORM
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