Form 843

OMB No. 1545-0024

Expires 6-30-96

Claim for Refund and Request for Abatement (Rev. June 1993)

Department of the Treasury

Internal Revenue Service © See separate instructions.

If your claim is for an overpayment of income taxes, DO NOT use Form 843. (See instructions.)

Use Form 843 ONLY if your claim involves one of the taxes shown on lines 3a, 6, 7, or 8, or a refund or abatement of

interest, penalties, or additions to tax on line 4a.

Daytime telephone number

Name of claimant

( )

Address (number, street, and room or suite no.)

City or town, state, and ZIP code

Please type or print

Spouse’s social security number

Your social security number

Employer identification number

Name and address shown on return if different from above

1 Period—prepare a separate Form 843 for each tax period 2 Amount to be refunded or abated

From , 19 , to , 19 $

b Dates of payment ©

3a Type of tax, penalty, or addition to tax

Employment Estate Excise Gift Penalty IRC section ©

4a Request for abatement or refund of:

Interest under Rev. Proc. 87-42. Interest under Rev. Proc. 87-43.

A penalty or addition to tax as a result of erroneous advice from the IRS.

Type of return filed (see instructions)

709 720 IRS No(s). © 990-PF 2290

4720

706 940 941

Other (specify) See lines 6–8 on page 2 and the instructions for gasoline excise tax claims if you are not a

filer of Form 720. ©

For Paperwork Reduction Act Notice, see separate instructions. Cat. No. 10180R Form 843 (Rev. 6-93)

b

730

5 Explanations and additional claims. Explain why you believe this claim should be allowed, and show computation of tax

refund or abatement of interest, penalty, or addition to tax.

Under penalties of perjury, I declare that I have examined this claim, including accompanying schedules and statements,

and, to the best of my knowledge and belief, it is true, correct, and complete.

Director’s Stamp

(Date received)

Signature (Title, if applicable. Claims by corporations must be signed by an officer.) Date

Signature Date

Signature.—If you are filing Form 843 to request a refund or abatement relating to a joint return, both you and your spouse must

sign the claim. Claims filed by corporations must be signed by a corporate officer authorized to sign, and the signature must be

accompanied by the officer’s title.
Form 843 (Rev. 6-93) Page 2

6 Gasoline Wholesale Distributors

Claimant bought gasoline or a gasohol mixture at a price that included the excise tax and (a) sold it directly to a state or local

government for its exclusive use, (b) sold it directly to a nonprofit educational organization for its exclusive use, (c) used or

sold it as supplies for vessels or aircraft, or (d) sold it for export. Claimant qualifies as a gasoline wholesale distributor, sold

the fuel at a tax-excluded price, and obtained a certificate of ultimate purchase or proof of export from the buyer.

CRN Type of tax Rate Gallons of fuel Amount

301

312

312

312

Gasoline

Gasohol containing at least 10% alcohol

Gasohol containing at least 7.7% alcohol but less than 10% alcohol

Gasohol containing at least 5.7% alcohol but less than 7.7% alcohol

$.141*

.087*

.0994**

.1102**

Gasohol Blenders (See instructions.)

Claimant bought gasoline taxed at the full rate ($.141*) and blended it with alcohol to make gasohol. The gasohol was used

or sold for use in a trade or business.

CRN Percentage of alcohol in the mixture Rate Gallons of gasoline Amount

302 At least 10% alcohol

At least 7.7% alcohol but less than 10% alcohol

At least 5.7% alcohol but less than 7.7% alcohol

$.0444*

.0333**

.0242**

7

302

302

Off-Highway Business Use of Gasoline

Claimant bought gasoline at a price that included the excise tax and used that gasoline for an off-highway business use.

Exempt use Rate Gallons Amount

Gasoline, off-highway business use $.141*

8

CRN

301

* The rates shown are effective after November 30, 1990.

** The rates shown are effective after December 31, 1992.