Complete and use the button at the end to print for mailing.
Affidavit for Bad Debt Loss — Supplier
Reference SDCL 10-47B-133
SD EForm - 0843
Any licensed supplier may apply for a refund of fuel taxes paid on gasoline, gasohol, undyed diesel fuel sold to a customer who fails
to remit payment for such fuel. However, a supplier may collect this refund for a specific customer only once every three years. After
submitting this affidavit, the supplier becomes responsible for fuel taxes due on future sales to the same customer.
Once the Department of Revenue receives this affidavit, it will notify all licensed suppliers and marketers that:
the customer has been delinquent in the payment of fuel taxes
the customer is no longer entitled to delay payment of taxes to any supplier for the following three years
no further tax refunds will be paid to suppliers or marketers who sell fuel to this customer for a three-year period
To qualify for this refund, the supplier must provide the Department with sufficient written evidence to justify the claim and to enable
the Department to collect payment from the delinquent customer.
Attach copies of all documents identified below
Name & Address
Total Tax Claimed for Refund
I declare and affirm under the penalty of perjury that this report has been examined by me, and to the best of my knowledge
and belief is in all things true and correct.
PRINT FOR MAILING