Form B/l: Mft-Prl - Loss Of Taxable Fuel Petition For Refund
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2B&L: MFT-PRL
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LABAMA
EPARTMENT OF
EVENUE
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USINESS
ICENSE
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IVISION
RESET
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ECTION
P.O. Box 327540 • Montgomery, AL 36132-7540 • (334) 242-9608 • Fax (334) 242-1199
Loss of Taxable Fuel Petition For Refund
For Losses and Contamination of Motor Fuel as Listed in Section 40-17-329(j)
NAME
LICENSE NUMBER
ADDRESS
FEIN
CITY
STATE
ZIP
CONTACT PERSON
TELEPHONE NUMBER
(
)
E-MAIL ADDRESS
Check here if new address
CASUALTY LOSS CAUSED BY: (check one)
Fire
Lightning
Flood
Tornado
Explosion
Other (explain) __________________________________
Note: Attach copy of insurance report.
LOSS FORM:
Unsalable/Unusuable as highway fuel
Date of Loss: ___________________ Location of Loss: _______________________________________________________________
Explanation of circumstances surrounding loss:
TAX REFUND CALCULATION:
Gasoline
Undyed Diesel
Aviation Gas
Jet Fuel
1. Total gallons of loss
(round to whole gallons). . . .
2. Excise tax rate . . . . . . . . . . .
X
$0.16
X
$0.19
X
$0.095
X
$0.035
3. Refund Total
(line 1 multiplied by line 2) . .
I declare under the penalties of perjury that this claim has been examined by me and to the best of my knowledge and belief is true and
correct, and that the number of gallons claimed were lost, destroyed, or contaminated, and that said petitioner is entitled to such refund
under the provisions of Section 40-17-329(j).
Signature: _________________________________________________________________ Date: ____________________________
Title or Position: ______________________________________________________________________________________________
Records to clearly substantiate the above petition must be maintained by the petitioner 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 the loss occurred. Copies of insurance reports, police reports and other documentation to substantiate the claim must be attached
to the petition. Please see instructions for further details.
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