Form Mfr-44 - Application For Refund Non-Highway Clear Diesel/gasoline Page 4

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Form MFR-44 (Rev. 2/13)
Page 4
Application for Refund
Non-Highway Clear Diesel/Gasoline
FEIN: _________________________
SCHEDULE B PART III
Use the following tables to fill out details relating to purchase, suppliers, and vehicles/equipments used for the
gallons claimed during this period.
PURCHASES
List invoices below and attach copies to this form. Each invoice must be for a purchase of 25 gallons or more.
N0.
DATE
INVOICE NO
GALLONS
NO.
DATE
INVOICE NO
GALLONS
1.
16.
2.
17.
3.
18.
4.
19.
5.
20.
6.
21.
7.
22.
8.
23.
9.
24.
10.
25.
11.
26.
12.
27.
13.
28.
14.
29.
15.
30.
SUB-TOTALS GALLONS
SUB-TOTALS GALLONS
TOTALS GALLONS
_____________
Use this field if you are applying for clear diesel or gasoline used in agriculture equipment/vehicles only.
Place zeros in gallons column if bulk fuel storage is not maintained. Electronic fueling receipts are acceptable for use.

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