Mail Drop 521M
USE FUEL VENDOR
Fuel Tax Refund Compliance Unit
PO Box 2100
Phoenix AZ 85001-2100
• Complete online or in black ink
• Mail to the address above
Refund Period Beginning Date
Refund Period Ending Date
Refund Account Number
ADOT License Number
Doing Business As (DBA)
Refund Mailing Address
Check if changed
Contact Person Name
Contact Person Phone
A use fuel vendor in Arizona is required to be licensed. If you do not have a use fuel vendor license, you must submit a Motor Fuel
License Application, form # 96-0492, with this refund application.
This form must be used to apply for use fuel tax differential on use fuel sold to light class motor vehicles or exempt use class motor
vehicles. Refund on use fuel sold for use in qualifying motor vehicles is at the rate of $.08 per gallon.
All refund applications, with attachments, must be mailed to the address above. The vendor must keep a copy of the refund application
with attachments. The vendor must complete this form in its entirety and any other required forms. The request will be returned for any
missing information. Proper documentation must be kept to verify all claims for refund. If the amount you claim for refund is later
determined to be incorrect, you may be assessed for tax due subject to penalty and interest pursuant to Arizona law.
Total Gallons Claimed For Refund
from Use Fuel Vendor Summary Detail, form #96-0152A, for multiple branches
from Use Fuel Vendor Branch Worksheet, form #96-0152B, for a single branch
I certify that the Arizona taxes have been paid on all of the gallons claimed above. The original, unaltered invoices (and supporting
documents) for the gallons claimed will be maintained for three years.
Signature (must be original, wet signature)
Must be signed by the licensee or an authorized officer of the business. All other signatures require a notarized power of attorney.
QTRFR Verified Date Claim Number