Form 8849

OMB No. 1545-1420

Expires 12-31-96 (January 1994) Claim for Refund of Excise Taxes

Department of the Treasury

Internal Revenue Service © See separate instructions.

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

Employer identification number

Social security number

Name and address shown on Form 720, 730, or 2290 if different from above

1 2 Amount to be refunded

$

Type of return filed, if any (see instructions)

720 2290

For Paperwork Reduction Act Notice, see separate instructions. Cat. No. 20027J Form 8849 (1-94)

730

3 Gasoline Wholesale Distributors (See instructions.)

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 purchaser or proof of export from the buyer.

CRN Type of fuel Rate Gallons of fuel Amount of refund

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

$.184

.13

.1424

.1532

Gasohol Blenders (See instructions.)

Claimant bought gasoline taxed at the full rate ($.184) 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 gasohol Rate Gallons of gasoline Amount of refund

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

$.0396

.0298

.0216

4

302

302

Off-Highway Business Use of Gasoline (See instructions.)

Claimant used gasoline for an off-highway business use.

Rate Gallons Amount of refund

Gasoline, off-highway business use $.184

5

CRN

301

Registered Ultimate Vendors of Diesel Fuel (claims for fuel sold to a buyer for the buyer’s use on a farm for

farming purposes or to a state or local government for its exclusive use) (See instructions.)

Claimant sold undyed diesel fuel (a) to a state or local government for its exclusive use or (b) for use on the buyer’s farm

for farming purposes. Claimant qualifies as a registered ultimate vendor, sold the fuel at a tax-excluded price, certifies that

the diesel fuel did not contain visible evidence of dye, and obtained the required certificate from the buyer and has no

reason to believe any information in the certificate is false.

Rate Gallons Amount of refund

Diesel fuel $.244

6

CRN

303

Period of claim © From , 19 , to , 19 .

Period of claim © From , 19 , to , 19 .

Period of claim © From , 19 , to , 19 .

Period of claim © From , 19 , to , 19 .

Income Tax Year © 
Form 8849 (1-94) Page 2

Train and Intercity Bus Use of Undyed Diesel Fuel (See instructions.)

Claimant bought undyed diesel fuel, certifies that the diesel fuel did not contain visible evidence of dye, and used the

diesel fuel in an engine that propels a diesel-powered train or an automobile bus.

CRN

Diesel-powered trains

8

Rate Gallons

Certain buses

$.175

$.17

305

305

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

to be refunded. Also include claims for fuel not covered on lines 3–8.

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. 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.

Nontaxable Use of Undyed Diesel Fuel (except for use on a farm for farming purposes or the exclusive use of a

state or local government) (See instructions.)

Claimant bought undyed diesel fuel, certifies that the diesel fuel did not contain visible evidence of dye, and used that diesel

fuel for a nontaxable use.

Nontaxable use Rate Gallons Amount of refund

$.244

7

CRN

303

Period of claim © From , 19 , to , 19 .

Period of claim © From , 19 , to , 19 .

Income Tax Year ©

Income Tax Year ©

Amount of refund