Form Mfd-33 - Licensed Distributor Application For Refund
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1MFD-33
Mailing Address:
(Rev. 2/05)
Georgia Department of Revenue
Taxpayer Services Division
Clear Form
Motor Fuel Tax Unit
1800 Century Center Blvd NE
Suite 8223
Print Form
Atlanta, GA 30345-3205
Licensed Distributor Application for Refund
GA Distributor License No. _________________ Date of Claim: ______________________
Federal Employer Identification No: (FEIN) ___________________
Name of Taxpayer: ___________________________________________________________________
Trade Name of Business (dba) ___________________________________________________________
Business Address: ____________________________________________________________________
Mailing Address if not same as above: ____________________________________________________
Claim Period:
From: ___________________________
To: __________________________
Type of Refund Claim Filed: Excise Tax
Prepaid State Tax
Both
Fuel Type:
Tax Amount Paid
Gallons Claimed
Amount Claimed for Refund
Gasoline
______________
_______________
______________________
Diesel Fuel
______________
_______________
______________________
Other: _________
______________
_______________
______________________
Deponent verily believes that this claim should be allowed for the following reasons:
OATH
State of _______________________
County of _____________________
The deponent, being duly sworn according to law, deposes and says that this statement is made on my behalf of
the taxpayer named, and that the facts given are true and correct.
___________________________________
Signature of Deponent
Subscribed and sworn to this ____________ day of _______________ , 20 ___
___________________________________________________________________________________________________
Notary Public
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