Form 1784 - South Dakota Summary For Amending Motor Fuel Tax Returns

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SD EForm - 1784
V2
Complete and use the button at the end to print for mailing.
HELP
SUMMARY FOR AMENDING
Department of Revenue
MOTOR FUEL TAX RETURNS
Motor Fuel Tax
445 East Capitol Avenue
Pierre, SD 57501-3100
Please Type or Print:
1. License Number:_____________________________________________________________
2. Federal ID or Social Security Number:____________________________________________
3. Business Name:_____________________________________________________________
4. Mailing Address:_____________________________________________________________
5. City:____________________________ State:_______________ Zip____________________
6. Amount overpaid/underpaid:$___________________________________________________
7. For the period(s) of:___________________________________________________________
8. State full and complete reasons for the error(s) in reporting which resulted in the above listed
over/under payment:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
These figures are provided to the best of my knowledge and I understand that this form does not
restrict the Department of Revenue from performing an audit of my records.
Name (Please Print):____________________________________________________________
Signature:______________________________________________ Date:__________________
Title:____________________________________ Telephone Number:_____________________
_____________________________________________________________________________
(For Department Use Only)
DOR Comments:_______________________________________________________________
_____________________________________________________________________________
Postmark:_________________________________
Reviewed By:_______________________________________ Date:______________________
MF056 07/11
All amended returns covering the periods indicated above must accompany this form
PRINT FOR MAILING
CLEAR FORM

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