Form Pet 354 - Specialized Equipment Claim For Refund - Tennessee Department Of Revenue
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1
2PET
354
TENNESSEE DEPARTMENT OF REVENUE
SPECIALIZED EQUIPMENT CLAIM FOR REFUND
1. Name of Claimant __________________________________________
2. SSN/FEIN __________________________________
Location Address __________________________________________
Account No. _________________________________
City, State, ZIP _____________________________________________
3. Date of Claim _______________________________
Mailing Address ___________________________________________
4. Claim Period: _______________________________
Semi-Annual Period Ending
City, State, ZIP _____________________________________________
DIESEL
GASOLINE
5. Total gallons from tax-paid bulk storage ..........................................................................................
6. Total gallons purchased from service stations (tax paid) ..............................................................
7. TOTAL GALLONS .............................................................................................................................
DIESEL REFUND
8.
.
a. Separate Aux. Motors GAL. ______________ X 16¢ ................ (Truck Refrig. or Concrete Mixers) ..... = $ _______________________________
.
b. Power Take-Off Units GAL. ______________ X 17¢ X 40% .... (Concrete Mixers & Pumpers) ............. = $ _______________________________
.
c. Power Take-Off Units GAL. ______________ X 17¢ X 10% .... (Pneumatic & Boom Unloaders) ........... = $ _______________________________
.
d. Power Take-Off Units GAL. ______________ X 17¢ X 90% .... (Mobile Self-Propelled Rock Drills) ....... = $ _______________________________
.
e. No. Capacity Unloadings __________________ X 2.5 Gal. X 17¢ (Pump Unloaders) ................................ = $ _______________________________
.
f. TOTAL AMOUNT CLAIMED ...............................................................................................................................
$ _______________________________
GASOLINE REFUND
9.
.
a. Separate Aux. Motors GAL. ______________ X 19¢ ................ (Truck Refrig. or Concrete Mixers) ..... = $ _______________________________
.
b. Power Take-Off Units GAL. ______________ X 20¢ X 40% .... (Concrete Mixers & Pumpers) ............. = $ _______________________________
.
c. Power Take-Off Units GAL. ______________ X 20¢ X 10% .... (Pneumatic & Boom Unloaders) ........... = $ _______________________________
.
d. Power Take-Off Units GAL. ______________ X 20¢ X 90% .... (Mobile Self-Propelled Rock Drills) ....... = $ _______________________________
.
e. No. Capacity Unloadings __________________ X 2.5 Gal. X 20¢ (Pump Unloaders) ................................ = $ _______________________________
.
f. TOTAL AMOUNT CLAIMED ...............................................................................................................................
$ _______________________________
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-R0008401
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