Form Mc059 - Motor Vehicle Fuel (Gasoline) Tax Refund Request
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1NEVADA DMV MOTOR CARRIER DIVISION
MOTOR VEHICLE FUEL (GASOLINE) TAX REFUND REQUEST
FARMER AND/OR RANCHER
_________________________________________________ Account No._______________________________________
Name of Claimant
_________________________________________________
Street Address or P. O. Box Number
_________________________________________________
(
) CHECK HERE IF YOU HAVE A NEW ADDRESS
City
State
Zip Code
GENERAL INSTRUCTIONS AND INFORMATION
1. Bulk purchases means purchases in excess of 50 gallons of gasoline. (Do not include diesel fuel.)
2. Any person determined by the Department to be a bona fide farmer or rancher not engaged in other activities which
would distort highway usage may claim a refund on the basis of 80 percent of bulk purchases without the necessity of
maintaining records. A farmer or rancher wishing to claim a refund must first secure a permit from the NEVADA DMV
MOTOR CARRIER DIVISION
3. Only the customer’s original copy of an invoice is acceptable for a refund claim. If an original invoice is lost or
st
destroyed, a claim may be submitted with a duplicate (1
carbon copy) invoice. A statement must accompany the claim
stating the original invoice has been lost or destroyed. Under no circumstances will photocopies of invoices be accepted. A
separate claim must be submitted in cases where a duplicate invoice is used to substantiate the purchase. The Department
of Taxation for a period of 12 months will hold such claims from date of purchase after which time they will be processed.
4. Claims for refund must be submitted within 12 months from the date of the earliest invoice and must be for bulk
purchases that total of a minimum of 200 gallons. Name on invoice must match name on Gas Tax Refund Account.
5. List original invoices below and attach them to this claim.
6. Send this application, properly signed, with original invoices attached to: Nevada DMV Motor Carrier Division, 555
Wright Way, Carson City, Nevada 89711.
NUMBER
NUMBER
NUMBER
INVOICE
INVOICE
OF GALLONS
INVOICE
INVOICE
OF GALLONS
INVOICE
INVOICE
OF GALLONS
NUMBER
DATE
PURCHASED
NUMBER
DATE
PURCHASED
NUMBER
DATE
PURCHASED
27 – 32 CENTS
1 CENT
Use whole gallons only
(STATE/COUNTY)
OPTION TAX
Total gallons purchased (Gasoline)
Less 20 percent for highway use
Total gallons claimed for refund
minimum 200 gallons
Rate of refund
.0098
Refund amount
County in which gasoline was TAXED ________________________
NOTE: Submit a separate claim for each county in which you purchased fuel for which you are claiming a refund.
I, the undersigned, certify the fuel claimed for refund as stated above, and documented by the attached original invoices, was
purchased and used in a farm or ranch operation, not more than 20 percent was used on public roads or highways, the dates
shown on the invoices are true and correct, and I am entitled to a refund under the provisions of NRS 365.
Claimant or Authorized Signature: ________________________________________________ Date ______________
Phone___________________________ Email Address: _________________________________________________
Federal Identification or Social Security Number: __________________________ (
) Check here if you need more forms
MC059 (07/2015)
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