Form 8849 - Claim For Refund Of Excise Taxes
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1
28849
Form
Claim for Refund of Excise Taxes
(Rev. January 1997)
OMB No. 1545-1420
Department of the Treasury
See separate instructions.
Internal Revenue Service
Name of claimant
Taxpayer identification number
Address (number, street, and room or suite no.)
Telephone number
(
)
City or town, state, and ZIP code
Month your income tax year ends
1
Type of excise tax return filed, if any (See instructions.)
2
Total amount to be refunded
720
730
2290
$
Caution: Complete all applicable entries or your claim will be delayed.
3
Gasoline Wholesale Distributors
Period of claim
Rate
Gallons
Amount of refund
CRN
Claimant bought gasoline or gasohol at a price that included the excise
tax and sold it directly to a state or local government for its exclusive
use; directly to a nonprofit educational organization for its exclusive use;
as supplies for vessels or aircraft; for export; or for use in the production
of special fuels. Claimant qualifies as a gasoline wholesale distributor,
sold the fuel at a tax-excluded price, and obtained a certificate of
ultimate purchaser or proof of export from the buyer.
a
Gasoline
$.
301
b
Gasohol containing at least 10% alcohol
.
c
Gasohol containing at least 7.7% alcohol but less than 10% alcohol
.
312
d
Gasohol containing at least 5.7% alcohol but less than 7.7% alcohol
.
4
Nontaxable Use of Gasoline
Period of claim
Type of use
Rate
Gallons
Amount of refund
CRN
Nontaxable use
$.
301
5
Nontaxable Use of Gasohol
Period of claim
Type of use
Rate
Gallons
Amount of refund
CRN
a
Gasohol containing at least 10% alcohol
$.
b
Gasohol containing at least 7.7% alcohol but less than
10% alcohol
.
312
c
Gasohol containing at least 5.7% alcohol but less than
7.7% alcohol
.
6
Nontaxable Use of Undyed Diesel Fuel (Lines 6a and b)
Period of claim
Sales by Registered Ultimate Vendors of Undyed Diesel Fuel (Line 6c)
Claimant certifies that the diesel fuel did not contain visible evidence of dye.
If any of the diesel fuel included in this claim did contain visible evidence of dye, attach a detailed explanation and check here
Type of use
Rate
Gallons
Amount of refund
CRN
Caution: You cannot make a claim for refund on lines 6a
or 6b for the tax paid on diesel fuel that you used on a farm
for farming purposes or on diesel fuel for the exclusive use
of a state or local government.
Lines 6a and b: Claimant has the name and address of the
person(s) who sold the diesel fuel to the claimant and the
date(s) of the purchase(s) and if exported, the required proof
of export.
a
$.
Heating oil
b
Other nontaxable use
.
303
c
Claimant, a registered ultimate vendor, sold diesel fuel
for use by the buyer on a farm for farming purposes or to
a state or local government for its exclusive use. Claimant
obtained the required certificate from the buyer and has no
reason to believe any of the information in the certificate is
false.
.
8849
For Paperwork Reduction Act Notice, see separate instructions.
Cat. No. 20027J
Form
(Rev. 1-97)
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