Form Boe-770-Du - Diesel Fuel Claim For Refund On Nontaxable Uses
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6BOE-770-DU (S1F) REV. 7 (9-12)
STATE OF CALIFORNIA
BOARD OF EQUALIZATION
BOE USE ONLY
DIESEL FUEL CLAIM FOR REFUND ON NONTAXABLE USES
RA-B/A
AUD
REG
CLAIM PERIOD
/
/
/
/
THROUGH
RR-QS
FILE
REF
YOUR ACCOUNT NO.
[
]
FOID
EFF
BOARD OF EQUALIZATION
SPECIAL TAXES AND FEES
PO BOX 942879
SACRAMENTO CA 94279-2050
READ INSTRUCTIONS
READ INSTRUCTIONS
BEFORE PREPARING
BEFORE PREPARING
As a user of tax-paid diesel fuel, you may file a claim for refund of tax paid on
diesel fuel used in an exempt manner. All
undyed
transactions supporting the amount claimed must be reported on form BOE 810-FTG, Receipt Schedule, or on BOE-810-FTF,
Disbursement Schedule.
Enter the beginning and ending dates of the period covered by this claim as mm/dd/yy in the box above.
You must submit completed Schedules 1A and 2A with your claim using BOE-810-FTG, Receipt Schedule. Where required to
support your claim, you must submit completed Schedules 12A through 12C and 13J through 13J9 with your claim. All
transactions supporting the amount claimed must be reported using BOE-810-FTF,
.
Disbursement Schedule
Note: Please read the attached instructions before completing the claim.
REPORT WHOLE
GALLONS ONLY
(B)
(A)
Diesel Fuel at
Diesel Fuel at
Prior Rate
Current Rate
1. Gallons of tax-paid diesel fuel claimed for refund of tax (enter from Refund
Computation Worksheet, line 7, columns A and B)
2. Rates of tax per gallon
$
$
3. Subtotal of refund amount (multiply line 1 by line 2 for columns A and B)
$
$
$
4. Amount of refund claimed (add columns A and B of line 3)
As provided in section 60501 of the Diesel Fuel Tax Law, I hereby file a claim for refund of the tax paid on tax-paid
diesel
undyed
fuel used for the purposes reported on the accompanying schedules. This claim covers the period identified above.
CERTIFICATION
I hereby consent to disclose and authorize the Board of Equalization (BOE) to release, as necessary, certain otherwise confidential
transaction information regarding volumes, invoice numbers, bills of lading, locations, dates, or method of delivery of reportable
products to any person identified by me in this return as being involved in a reported transaction for the sole purpose of verifying
the accuracy of the reportable product transaction information concerning my transactions with such person as reported in this
return.
I, the undersigned, certify that, to the best of my knowledge, all of the information on this claim and any accompanying documents
is true, correct, and complete and that I am duly authorized to sign for the claimant. I further certify that the diesel fuel covered by
this claim included the diesel fuel tax in the purchase price of the diesel fuel and did not contain visible evidence of dye.
SIGNATURE
DATE
TELEPHONE
(
)
PRINT NAME AND TITLE
EMAIL ADDRESS
CLEAR
PRINT
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