Form Mfr-44 - Application For Refund Non-Highway Clear Diesel/gasoline Page 5

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Form MFR-44 (Rev. 2/13)
Page 5
Application for Refund
Non-Highway Clear Diesel/Gasoline
FEIN: _________________________
OATH
State of _____________________________________
County of ____________________________________
The deponent, being duly sworn according to law, deposed and says that this statement is made on my
behalf on the taxpayer names, and that the facts given are true and correct.
_________________________
_________________
______________________
Phone
Title
Signature of Deponent
Subscribed and sworn to this _______ day of ____________, 20___
Notary Public

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