Form Mfr-44 - Application For Refund Non-Highway Clear Diesel/gasoline Page 2
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Form MFR-44 (Rev. 2/13)
Page 2
Application for Refund
Non-Highway Clear Diesel/Gasoline
FEIN: _________________________
SCHEDULE A PART I
CLAIM ON CLEAR DIESEL USE TAX
Claim may be for the 7 1/2 cents per gallon excise tax on the non - highway use of taxable clear diesel fuel.
Refund claim must be filed within 18 months of the taxable clear diesel purchase.
Account below for all clear diesel consumed during the period covered by this claim. Then, use the tables under
SCHEDULE B PART III (on page 4) to fill out the necessary information.
12.
12. Quantity of Fuel Purchased during Period (in gallons) : ……………………………………..
(Total of Invoices Listed)
13.
13. Plus, Bulk Fuel Inventory Brought Forward from Previous Claims (in gallons): …………..
End of Period (in gallons):
14. (
14. Less Quantity of Fuel on Hand at
………………………………
)
15. Less Quantity of Fuel Used on Highway (in gallons) : ……………………………………….
15. (
)
16. Total Gallons on which Refund is Claimed: ………………………………………………….
16.
Reason Clear Diesel Used Off Highway:
SCHEDULE A PART II
SUPPLIER INFORMATION
List name and address of suppliers from which you purchased the fuel that you are claiming refunds on.
NAME OF SUPPLIER
STREET ADDRESS
CITY
STATE
ZIP CODE
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