Form 84 - Nebraska Motor Fuels Tax Refund Claim
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1Nebraska Motor Fuels Tax Refund Claim
FORM
84
RESET FORM
• Read instructions on reverse side
Nebraska ID
Federal Employer ID
Period Covered by this Claim
Beginning ____________________,20_____ Ending ____________________, 20_____
NAME AND ADDRESS OF CLAIMANT
Name
E-mail Address
Street Address
Mailing Address If Different Than Street Address
City
State
Zip Code
Contact Person
Telephone Number
Indicate reason for the claim:
Use in unlicensed equipment. Indicate general type of equipment ____________________
Purchases by agencies of the federal government
Use in refrigeration units
Gasoline used as aviation fuel
Accidental contamination of fuel: Types of fuel ___________________________________
Other ___________________________________
Was this fuel withdrawn from a bulk storage tank which was also used to fuel licensed vehicles?
YES
NO
Additional information:
For Dept. of
Revenue
Less: Adjustments
Net Amount
Use Only
Product
Gallons
Refund Rate
Amount
(see instructions)
Claimed
Approved
*
Gasoline, Gasohol, Ethanol
X
=
$
.00
$
.00
$
.00
$
Approved
*
Undyed Diesel
X
=
$
.00
$
.00
$
.00
$
$0.05
Aviation Gasoline
X
=
$
.00
$0.03
Jet Fuel
X
=
$
.00
Approved
*
Total Aviation Fuels
$
.00
$
.00
$
.00
$
*If this amount is less than $25 within a calendar year, you are not eligible for a refund.
Petroleum Release Remedial Action Fee
Motor Vehicle Fuels
X
$0.009
=
$
.00
$0.003
Other Petroleum Products
X
=
$
.00
Approved
**
Total Fee
$
.00
$
**If this amount is less than $10 within a calendar year, you are not eligible for a refund.
Under penalties of law, I declare that I have examined this claim and to the best of my knowledge and belief, it is correct and complete. I further declare that unless used by
an agency of the federal government, a Native American, or by buses for hire, none of the fuel claimed for refund was used in a licensed motor vehicle. I also declare that payment
of this claim has not been previously made by the state and records supporting this claim are subject to audit for a period of three years from the date the claim was filed.
sign
here
Authorized Signature
Telephone Number
Signature of Preparer Other Than Taxpayer
Telephone Number
Title
Date
Address
FOR MOTOR FUELS DIVISION USE ONLY
APPROVED
COMMENTS:
APPROVED AS ADJUSTED
DISAPPROVED
Authorized Signature
Date
Mail this claim, with substantiating documentation to: MOTOR FUELS DIVISION, P.O. BOX 98904, LINCOLN, NE 68509-8904
12-2004
3-194-1975 Rev.
Supersedes 3-194-1975 Rev. 7-2001
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