Form Mfr-44 - Application For Refund Non-Highway Clear Diesel/gasoline Page 3
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Form MFR-44 (Rev. 2/13)
Page 3
Application for Refund
Non-Highway Clear Diesel/Gasoline
FEIN: _________________________
SCHEDULE B PART I
CLAIM ON GASOLINE (AGRICULTURE EQUIPMENT USE) TAX
Account below for all gasoline 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. Claims must be filed within one year of purchase.
12.
12. Enter total gallons from the Purchased table below: …………………………………………..
13.
Fuel consumed in trucks, autos, Jeeps and other equipment that IS NOT
13.
classified as agricultural field use vehicle …………………………………………………… …
14. Fuel consumed by farm equipment while traveling on highways ………………………… ….
14.
15. Fuel consumed performing work on property that is not owned, leased or share-cropped
15.
by you ………………………………………………………………………………………………
16.
16. Fuel consumed on farm but not connected with farming operations ………………………..
17. Any other taxable use (Specify)
17a.
a.
17b.
b.
18. Sub-Total Lines 13-17 ..........................................……………………………………………..
18.
19. Quantity refund claimed on Line 12 minus Line 18……………………………………………..
19.
(Use the Vehicle/Equipment Used table to show how claimed gallons were consumed)
SCHEDULE B PART II
VEHICLE/EQUIPMENT USED
List the non-highway/agriculture vehicle(s) or equipment(s) used. Provide all the applicable information.
EQUIPMENT TYPE
SERIAL NO.
YEAR
TYPE OF WORK PERFORMED
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Signature: ________________________ Title: __________________________ Date: ______________
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