Form Dr-189 Draft - Application For Fuel Tax Refund Municipalities, Counties And School Districts
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1
2
3Application for Fuel Tax Refund
DR-189
R. 01/18
Municipalities, Counties and School Districts
Rule 12B-5.150
For the Quarter Ending
Florida Administrative Code
Effective 01/18
Check here if amending
Mail To:
Florida Department of Revenue
Refunds
P.O. Box 6490
Tallahassee FL 32314-6490
For Help Call: 850-617-8585
Permit #:
FEIN:
Business Partner #:
Column A
Column B
Gasoline, Gasohol and
Gallons
Undyed Diesel Fuel
Gasoline/Gasohol
Undyed Diesel
1. Beginning inventory
(Must agree with
,
,
.
,
,
.
closing inventory from prior quarter) ..............
2. Gallons purchased
("Schedule of
,
,
.
,
,
.
Purchases" attached) .....................................
3. Closing inventory
(Use this figure for
,
,
.
,
,
.
beginning inventory on next claim) ................
4. Total consumption
(Add Lines 1 and 2.
,
,
.
,
,
.
Subtract Line 3) ..............................................
5. Gallons not eligible for refund
,
,
.
,
,
.
(Off-road use) .................................................
6. Gallons claimed for refund
(Subtract
,
,
.
,
,
.
Line 5 from Line 4) ..........................................
$
,
,
.
$
,
,
.
7. Refund
(Lines 6A and 6B X
.1 4
1) .............
See item eight on reverse page if any of the gallons claimed on Line 6 were purchased during the previous calendar year.
Net Refund Due (Add Lines 7A and 7B)
$
,
,
.
No refund will be issued for less than $5.00.
Under penalty of perjury, I declare that I have read this application and the facts stated in it are true.
____________________________________________
__________________________________________
Signature of Applicant
Contact Person
____________________________________________
__________________________________________
Print/Type Applicant Name
Contact Telephone Number
____________________________________________
__________________________________________
Date
Contact Email address
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Parent category: Financial