Form B/l: Mft-Prc - Credit Card Issuer Petition For Refund
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B&L: MFT-PRC
RESET
LABAMA
EPARTMENT OF
EVENUE
1/12
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
Credit Card Issuer Petition for Refund
For Gasoline and Diesel Fuel Purchases by Licensed Exempt Entities
NAME
QUARTER ENDING
ADDRESS
FEIN
CITY
STATE
ZIP
CONTACT PERSON
TELEPHONE NUMBER
(
)
E-MAIL ADDRESS
Check here if new address
TAX REFUND CALCULATION:
Gasoline
Undyed Diesel
1. Total gallons billed to licensed exempt entities
without the excise tax (round to whole gallons) . . . . . . . . . . . . .
$0.16
$0.19
2. Excise tax rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
X
X
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 billed 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(f).
Signature: _________________________________________________________________ Date: ____________________________
Title or Position: ______________________________________________________________________________________________
Records to clearly substantiate the above petition must be maintained by the credit card issuer 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 credit card purchase was made by the licensed exempt entity. The petition must be filed on a quarterly basis with a
separate petition for each quarter and cannot include any purchases for any other period. A listing of purchases must be attached
stating the date of the credit card purchase made by the licensed exempt entity, the licensed exempt entity name, exempt license
number, vendor name and location, invoice number, product type, and number of gasoline and/or undyed diesel fuel gallons. Please
see instructions for further details.
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