Form B/l: Mft-Prd - Licensed Distributor Petition For Refund
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1
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3B&L: MFT-PRD
A
D
R
LABAMA
EPARTMENT OF
EVENUE
RESET
6/12
B
& L
T
D
USINESS
ICENSE
AX
IVISION
M
F
S
OTOR
UELS
ECTION
P.O. Box 327540 • Montgomery, AL 36132-7540 • (334) 242-9608 • Fax (334) 242-1199
Licensed Distributor Petition for Refund
For Motor Fuel Sales to Exempt Entities Licensed in Accordance with Section 40-17-332(j)
NAME
MONTH ENDING
ADDRESS
LICENSE NUMBER
CITY
STATE
ZIP
FEIN
CONTACT PERSON
TELEPHONE NUMBER
(
)
E-MAIL ADDRESS
Check here if new address
TAX REFUND CALCULATION:
Gasoline
Undyed Diesel
Aviation Gas
Jet Fuel
1. Total gallons sold to licensed exempt
entities (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) . . . . . . . . .
REFUND ALLOWANCE CALCULATION:
4. Total gallons sold to licensed exempt
entities (round to whole gallons) . . . .
5. Refund allowance rate . . . . . . . . . . . .
X
$0.02
X
$0.02
6. Allowance total
(line 4 multiplied by line 5) . . . . . . . . .
7. Total Refund and Allowance
Due (line 3 plus line 6) . . . . . . . . . .
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 sold to the licensed exempt entities without the state excise tax, and that said petitioner is entitled
to such refund under the provisions of Section 40-17-329(b).
Signature: _________________________________________________________________ Date: ___________________________________
Title or Position: _____________________________________________________________________________________________________
Records to clearly substantiate the above petition must be maintained by the licensed distributor 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
sale of the fuel to the licensed exempt entity. The petition must be filed on a monthly basis with a separate petition for each month and cannot
include any sales for any other period. A summary listing of sales must be attached stating the licensed exempt entity name, license number,
and number of motor fuel gallons. Please see instructions for further details.
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Parent category: Financial