Form Idr-277-C - Claim For Refund Single Trip Interstate Motor Fuel Use Tax Permit (2010)

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Illinois Department of Revenue
Claim for Refund
IDR-277-C
Single Trip Interstate Motor Fuel Use Tax Permit
Who should fi le this form?
Approved permit providers must complete Form IDR-277-C to receive a refund for voided Single Trip Interstate Motor Fuel Use Tax Permits
returned to the Illinois Department of Revenue. A separate claim must be fi led for each permit that has been returned.
Where do I send my completed Form IDR-277-C?
Mail your completed Form IDR-277-C and voided permit to
ILLINOIS DEPARTMENT OF REVENUE
PO BOX 19018
SPRINGFIELD IL 62794-9018
Step 1: Identify your business
__ __ __ __ __ __ __ __
Account ID:
ST - __ __ __ __ __
License no.:
Name:
_______________________________________________
Address: _______________________________________________
City:______________________________
ZIP:________________
Step 2: Check all that apply to the reason you are completing this claim
1
_____ Typed the wrong information on the permit.
2
_____ Discovered the driver did not need permit after it was issued.
3
_____ Issued for incorrect state or agency.
4
_____ Other - Describe the situation. Attach additional sheets if needed.
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Step 3: Figure your claim amount
5
Write the voided permit number:___________________________
You must attach it to this claim.
$40.00
6
Permit fee to be refunded:
Step 4: Sign below
I certify that, to the best of my knowledge, the information on this claim for refund is true and accurate and that I am seeking a refund for
payment of a permit that was never issued, but was voided for the reason indicated above.
Offi cial Use
_______________________________________________
___ ___/___ ___/___ ___ ___ ___
No
____________
Signature
Date
Amt
____________
Apv
____________
Vrf
____________
*092201110*
DR
____________
Int D
____________
IDR-277-C (R-04/10)
This form is authorized by the Motor Fuel Tax Law. Disclosure of information is REQUIRED. Failure to comply
IL-492-4593
may result in a penalty. This form has been approved by the Forms Management Center.
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