Form Dmf-80 - Reimbursement Request For Motor Fuel Taxes Paid On Sales To Government/exempt Entities

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DMF-80 (12-12)
Reimbursement Request
for Motor Fuel Taxes
BUREAU OF MOTOR AND
Paid on Sales to
ALTERNATIVE FUEL TAXES
Government/Exempt
PO BOX 280646
HARRISBURG, PA 17128-0646
Entities
PHONE 717.783.9367 | FAX 717.787.6261
This form is used by non-permitted dealers and retailers of motor fuels to obtain a reimbursement of motor fuel
taxes paid on fuels purchased (tax included), and subsequently sold tax-free to government and other entities
exempted from the Pennsylvania liquid fuels and fuels tax.
SEE REVERSE FOR INSTRUCTIONS
1. Applicant Information:
NAME
ADDRESS
CITY, STATE AND ZIP CODE
Federal Employer ID Number (FEIN) or
Social Security Number (SSN)
Telephone Number
2. Reimbursement Information:
A. Refund Period: From
To
Gallons of
Gallons of
Amount of
Amount of
B.
Name of Exempt Entity
Gasoline Sold
Undyed
Refund for
Refund for
Diesel Sold
Gasoline Sales
Diesel Sales
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
TOTALS
$
$
C. Total Reimbursement Requested: $
3. Certification: I certify to the best of my knowledge, the tax for which reimbursement is requested was paid
and the fuel indicated above was sold tax-free.
Name
Signature
(please print)
Title
Date

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