Form Pet 357 - Governmental Sales Claim For Refund - Tennessee Department Of Revenue - 2016
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1
2PET
357
TENNESSEE DEPARTMENT OF REVENUE
GOVERNMENTAL SALES 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 _________________________________
If this is an omnibus claim,
please check box at right
COMPUTATION OF REFUND
1. Gasoline Tax (Total of Column A multiplied by $.196917) ........................................... $ _________________
2. Diesel Tax (Total of Column B multiplied by $.167379) ............................................... $ _________________
3. Special Tax (Total of Columns A, B, and C multiplied by $.01) ................................... $ _________________
4. Environmental Assurance Fee (Total of Columns A, B, and C multiplied by $.004) ... $ _________________
5. Total Refund Due (Total of lines 1, 2, 3, and 4) ........................................................... $ _________________
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-R0008501
INTERNET 04-16)
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