Petition For Gasoline Tax Refund - Alabama Department Of Revenue
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LABAMA
EPARTMENT OF
EVENUE
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& L
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USINESS
ICENSE
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IVISION
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OTOR
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P.O. Box 327540 • Montgomery, AL 36132-7540 • (334) 242-9608
Petition For Gasoline Tax Refund
SUBT: GR-5
Rev. 1/12
(NO DIESEL FUEL ALLOWED)
NAME
QUARTER ENDING
ADDRESS
FEIN OR SSN
CITY
STATE
ZIP CODE
PHONE NUMBER
(
)
EMAIL ADDRESS
CONTACT PERSON
Check Here
If New Address
INDICATE ORGANIZATION TYPE:
Gas District
Volunteer Fire Department
Water & Fire Authority
Charitable Organization
Other __________________________
PURCHASES OF GASOLINE IN ALABAMA FOR WHICH THIS PETITION IS BEING FILED
VENDOR NAME AND ADDRESS
DATE OF PURCHASE
GALLONS
(IF SPACE IS INSUFFICIENT, CONTINUE ON REVERSE SIDE)
TAX REFUND COMPUTATION
1
1. Total gallons listed above and on reverse side . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
X
$.16
2
2. Rate of refund per gallon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3
3. Amount of refund claimed (Line 1 multiplied by line 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
I hereby certify that to the best of my knowledge and belief the above petition is true and correct, that the gasoline claimed
thereon was purchased and paid for by the petitioner, and that said petitioner is entitled to such refund under the provisions
of Sections 40-9-9 through 40-9-13, 40-9-23, 11-22-13, 11-50-412, 11-88-16, or 22-51-13, Code of Alabama 1975.
Signature: _________________________________________________________________ Date: ____________________________
Title or Position: ______________________________________________________________________________________________
Records to clearly substantiate the above petition must be maintained by the applicant for a period of six years and must be made
available to the Alabama Department of Revenue or its authorized agents upon request. The statute of limitations is two years from
the date of purchase of fuel. A copy of receipts/invoices or a credit card report of purchases must be submitted with the petition for
refund. The receipts or reports must include the date of the purchase, name and location of vendor, product type, invoice number,
and number of gallons of fuel purchased.
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