Form Pet 371 - End User Claim For Refund - Tennessee Department Of Revenue

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PET
371
TENNESSEE DEPARTMENT OF REVENUE
END USER CLAIM FOR REFUND
Name of Claimant __________________________________________
SSN/FEIN ____________________________________
Location Address __________________________________________
Account No. ___________________________________
City, State, ZIP _____________________________________________
Claim Period:
Beginning ______________________
Mailing Address ___________________________________________
Ending ________________________
City, State, ZIP _____________________________________________
Date of Claim _________________________________
REQUIRED: Date of last purchase in this claim ____________
Date of last claim ____________
UNDYED
Check the box at left if you have reported and paid the sales and use tax due on
DIESEL
the total gallons on Line 6 below. Otherwise, see Sales & Use Tax Calulation
Schedule on the back of this claim.
GALLONS
1. Beginning Inventory ........................................................................................................................................................... (1)
_______________________
2. Purchases (Attach copies of invoices) (Schedule A) ...................................................................................... (2A) RETAIL _______________________
(2B) BULK
_______________________
3. Use - A. Heating fuel ................................................................................................................................................... (3A)
_______________________
B. Fabricating - Industrial Machinery # ___________________ .................................................................... (3B)
_______________________
C. Other non-highway, describe ________________________ (Schedule B) ............................................ (3C)
_______________________
D. Taxable use ................................................................................................................................................... (3D)
_______________________
4. Adjustments ....................................................................................................................................................................... (4)
_______________________
5. Ending Inventory (Carry forward to beginning inventory of next claim) .......................................................................... (5)
_______________________
6. Total of Line 3A, 3B, & 3C (Carry total gallons to be refunded to Sales & Use Tax Calculation Schedule on back) ...... (6)
_______________________
7. Maximum Diesel Tax Refund Amount (Line 6 multiplied by $0.17) .................................................................................... (7) $ ______________________
Note: The maximum refund amount is subject to a Sales & Use Tax liability as calculated on the back of this claim.
Minimum refund: $250.00
If less than $250.00, attach this completed report to subsequent claim (up to 2 years) until total claim exceeds $250.00.
OATH OF TAXPAYER
Under penalties of perjury, I declare that I have examined this claim, and to the best of my knowledge and belief, it is true, correct,
and complete.
Name ___________________________________________
Title ___________________________________________
(Signature of Taxpayer, Officer, or Authorized Representative)
FOR OFFICE USE ONLY
CHECKED BY
DATE
APPROVED
REASON FOR REDUCTION
REFUND NO.
REDUCED
PROCESS COMPLETION DATE
INCREASED
APPROVAL
Approved Amount $ ______________
__________________________________________
________________________________________
_____________
Director or Designate
Commissioner of Revenue or Designate
Date
RV-R0009101
INTERNET (4-03)

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