Form Ga-110lmp - Claim For Refund
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Indiana Department of Revenue
ga-110lmP
Claim for Refund
State Form 24721
(R3 / 4-08)
Sales Tax on Gasoline, Gasohol, & Special Fuel
Dispensed through Stationary Metered Pumps in Indiana
Name of Taxpayer
Taxpayer Identification (TID)
or Non-Profit Certification #
Street or P.O. Box
Social Security or
Federal ID #
City
State
Zip
FHWA or
IMCA #
Describe Exempt Use of Gasoline, Gasohol, or Special Fuel and period for which you are filing a refund. Attach additional sheets (if necessary):
Period:
Type Fuel:
Exempt Use:
Period:
Type Fuel:
Exempt Use:
PlEaSE NoTE
▼
▼
In order to complete this form, you will first need to obtain the current gasoline, gasohol, or fuel tax rate(s) from Departmental Notice
#12.You may review Departmental Notice # 12 on our web site at:
or by calling
the Department at (317) 232-2339.
Column A
Column B
Column C
Note: Special fuels include diesel fuel, lique-
gasoline
gasohol
Special fuel
fied petroleum (LP), compressed natural gas
(CNG), compressed methane, and propane.
1.
Total gallons purchased for exempt use per receipts.
gallons
gallons
gallons
2.
Total purchase price ................................................
.
.
.
3.
Current Rate. (From Departmental Notice #12) ......
4.
Total state and federal excise tax included in sales.
(Multiply Line 1 x Current Rate ) .............................
5.
Taxable amount. (Subtract Line 4 from Line 2) .......
6.
Total sales tax paid on exempt gallons for exempt
purposes. (See chart to calculate amount) .............
The person or organization representative signing this application hereby certifies that sales tax has been paid on the purchase of gasoline, gasohol, or
special fuel through a stationary metered pump as shown by attached receipts, such fuel has been used for a purpose which is exempted in Section IC
6-2.5 of the State Gross Retail Sales Act, and no other claim for refund has been filed on purchases shown on the attached receipts.
Signature of Applicant _____________________________________________________________ Telephone Number ____________________
Title ____________________________________________________________________________ Date _______________________________
For assistance call (317) 232-2339, or you may send an e-mail through our web
Mail to: Indiana Department of Revenue
site by accessing:
then select “sales tax”
100 N. Senate avenue, Room N203
as your subject title.
Indianapolis, IN 46204
foR DEPaRTmENTal uSE oNly
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If disallowed or adjusted - Explain
TOTAL AMOUNT OF REFUND
Warrant Number
Tax Analyst
Date
Warrant Date
supervisor/Administrator
Date
Account
Claim Number
User ID Number
Special
Signature on file
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