Form 8849 - Schedule 5 Section 4081(E) Claims
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1
2Schedule 5
Department of the Treasury—Internal Revenue Service
Section 4081(e) Claims
(Form 8849)
OMB No. 1545-1420
(Rev. January 2001)
Attach to Form 8849. Do not file with any other schedule.
Name as shown on Form 8849
EIN
Total refund
$
Claimant’s registration number.
Part I
Claim for Refund of Second Tax
(b)
Type of fuel
(a) Amount of refund
CRN
301
1
Gasoline
$
2
10% gasohol
312
3
7.7% gasohol
4
5.7% gasohol
307
5
Aviation gasoline
6
Diesel fuel
303
7
Kerosene
Part II
Supporting Information Required. See instructions. If more space is needed, attach separate sheets.
Claimant certifies that the amount of the second tax has not been included in the price of the fuel, and has not been
collected from the purchaser. Claimant has attached a copy of the First Taxpayer’s Report, and if applicable, a copy
of the Statement of Subsequent Seller.
(c) Type of fuel
(d)
(e) Gallons of fuel claimed
(f) Amount of second tax paid
(Enter line number
Date second tax liability incurred
Enter whole gallons only.
from Part I.)
Use MMDDYYYY format.
$
For Privacy Act and Paperwork Reduction Act Notice, see Form 8849 instructions.
Cat. No. 27453B
Schedule 5 (Form 8849) (Rev. 1-2001)
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