Form L-2133 - Motor Fuel Refund Application
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1
2STATE OF SOUTH CAROLINA
1350
DEPARTMENT OF REVENUE
L-2133
MOTOR FUEL REFUND APPLICATION
(Rev. 10/13/14)
4222
Mail to: SC Department of Revenue, Motor Fuel, Columbia, SC 29214-0139
Use a separate application for each refund type.
File Number
(Instructions on the back.)
NAME AND ADDRESS
Period Covered
SSN or FEIN
Telephone Number
A:
Type of Refund
Gasoline
LS Diesel
Other
Total Product
Federal Government
State School Bus *
Product Diverted to
(Enter State)
Contaminated Product *
Regional Transp Authority *
Other:
* Do not calculate fees for these refund types.
B:
Gasoline
gallons X $.16 = $
Gasoline Refund
(34-2301)
C:
Special Fuel
gallons X $.16 = $
Special Fuel Refund
(34-2101)
D:
Total Product
gallons X $.0025 = $
Inspec Fee Refund
(34-2314)
E:
Total Product
gallons X $.0050 = $
Enviro Fee Refund
(34-2312)
When signing this form, it is important that the information contained in your report be correct and complete. To
wilfully furnish a false or fraudulent statement to the Department is a crime.
Print Name:
Signature:
Date:
Email Address:
For Office Use Only
Audited by:
Date:
42221028
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Parent category: Financial