Sd Eform 0839 V1 - Affidavit Of Sale Of Undyed Diesel Fuel As Heating Oil
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SD EForm - 0839
V1
Affidavit of Sale of Undyed Diesel Fuel As Heating Oil
Reference SDCL 10-47B-128
Explanation
In the event that a customer is unable to purchase dyed diesel fuel for use as heating oil, a marketer or retailer may sell
undyed diesel fuel in its place. The marketer or retailer must then testify through affidavit that he or she was unable to obtain
dyed diesel fuel and had to substitute undyed diesel fuel. With this affidavit, the customer can then apply for a refund of fuel
taxes, but must pay sales tax on the cost of the fuel minus fuel tax.
Marketer/Retailer Information
Marketer/Retailer Name
License Number
Address
Customer Information (Refund Claimant)
Customer Name
Customer Address
Phone Number
Attach a copy of the original sales invoice and complete refund claim information below.
1 Total gallons of undyed diesel fuel purchased for use as heating fuel – Obtain from sales invoice
1
2 Fuel Tax Rate
2
$.22
3 Total Fuel Tax Paid – Multiply Line 1 by Line 2
3 $
0.00
4 Total Fuel Cost (including tax) – Obtain from sales invoice
4 $
5 $
5 Net Fuel Cost – Subtract Line 3 from Line 4
0.00
6 Sales Tax Due – Multiply amount on Line 5 by $0.04
6 $
0.00
7 Refund Amount – Subtract Line 6 from Line 3
7 $
0.00
Marketer/Retailer Signature
I declare and affirm under the penalty of perjury that on _____________________, 20________, I sold __________________
345,345
gallons of undyed (taxed) diesel fuel to the customer listed above because I was unable to obtain dyed diesel fuel from any of
my regular sources. I have informed the customer that sales tax due on the fuel will be deducted from the customer’s refund
of fuel taxes.
Signature
Title
Date
Notarization
Subscribed and sworn before me this __________ day
of _______________________, 20_______.
Affix Seal Here
________________________________________
Notary Public
My commission expires on ________________________
PRINT FOR MAILING
CLEAR FORM
1.
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