Form Ref-1000 - Consolidated Application For Fuel Tax Refund
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6Form REF-1000
Indiana Department of Revenue
State Form 50854
Consolidated Application for Fuel Tax Refund
(R5 / 4-13)
Refund Period Beginning _______________ Refund Period Ending _________________
Section I: Information
1. Name or Business Name (Please Type or Print)
2. Social Security Number
Address
3. Federal ID Number (if applicable)
City, State and ZIP
4. Taxpayer ID Number (TID)
5. County
6. License Type(s) (check box(es)) and number
A
B
C
Gasoline Distributor
Special Fuel Provider
License Number ________________________
7. Ownership Type (check one)
8. Use of Fuel (check one)
A
E
I
A
F
J
Sole Owner
Federal Govt.
Public Schools
Agriculture
Maintenance
Railroad
B
F
J
B
G
K
Partnership
State Govt.
Other (Specify)
Aviation
Manufacturing
Refrigeration
C
G
C
H
L
Commercial
Municipal Govt.
___________
Building/Const.
Marine
Taxicabs
D
H
D
I
M
Corporation
County Govt.
Export
Mining
Other (Specify)
E
Local Transit Systems
_____________
Section II: Computation
Type of Fuel
Gasoline
Special Fuel
1. Beginning Inventory (Use Whole Gallons)
1A
Gal
1B
Gal
2. Purchases (Attach Invoices)
2A
2B
3. Total Available Gallons (Add Lines 1 and 2)
3A
3B
4. Gallons Used for Taxable Purposes
4A
4B
5. Gallons Used for Nontaxable Purposes (Gallons Eligible
for Refund from Section III)
5A
5B
6. Ending Inventory (Subtract Lines 4 and 5 from Line 3)
6A
6B
7. Proportional Gallons Eligible for Refund (From Section
VI)
7A
7B
8. Total Gallons Eligible for Refund (Add Lines 5 and 7)
8A
8B
9. Fuel Tax Rate
9A
.18
9B
.16
10. Amount of Fuel Tax Refund (Line 8 x Line 9)
10A
10B
11. Adjustment for Collection Allowance (If applicable) See
Gasoline Does
Instructions.
11A
Not Apply
11B
12. Enter Amount of Sales Tax Due (See Instructions).
12A
12B
13. Enter Amount of Refund (Subtract Lines 11 and 12 from
Line 10)
13A
13B
This application must be signed by the taxpayer or authorized agent before it will be accepted by the department
(IC 6-6-1.1-904.1 and IC 6-6-2.5-32).
See Section VII: Signature/Authorization
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