Form Au-629 - Application For Refund/reimbursement Of Taxes Paid On Fuel Sold To Governmental Entities By Registered Distributors Page 3
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4AU-629 (4/11) Page 3 of 4
Schedule B - Diesel motor fuel sales to governmental entities
(Attach additional sheets if necessary)
Taxes prepaid by seller
Purchaser’s
Number of
Petroleum
Date of
Invoice
gallons sold
Name
City
County
Excise tax
business tax
Sales tax
sale
number
exempt
15 Total gallons purchased
(enter here and on lines 2, 5 and 8, Column A) ........
16 Total excise tax paid/refund claimed
(enter here and on line 2, Column B) ..........................
17 Total petroleum business tax paid/refund claimed
(enter here and on line 5, Column B) ...........................
18 Total prepaid sales tax paid/refund claimed
(enter here and on line 8, Column B) ....................................................................
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