OMB No. 1545-1420 Section 4081(e) Claims

(Rev. February 2005)

Department of the Treasury

Internal Revenue Service

Schedule 5

Name as shown on Form 8849

Claimant certifies that the amount of the second tax has not been included in the price of the fuel, and has not been

collected from the purchaser. Claimant has attached a copy of the First Taxpayer’s Report, and if applicable, a copy

of the Statement of Subsequent Seller.

Type of fuel

Gasoline

Aviation gasoline

(a)

Amount of refund

(Form 8849)

Total refund (see instructions)

(b)

CRN

For Privacy Act and Paperwork Reduction Act Notice, see Form 8849 instructions. Cat. No. 27453B Schedule 5 (Form 8849) (Rev. 2-2005)

362

324

Kerosene (other than aviation-grade kerosene)

 Attach to Form 8849. Do not file with any other schedule.

(c) Type of fuel

(Enter line number

from Part I.)

(d)

Date second tax liability incurred (f) 

Amount of second tax paid

(e)

Gallons of fuel claimed

Part I

Part II Supporting Information Required. See instructions. If more space is needed, attach separate sheets.

Claim for Refund of Second Tax

Diesel fuel

1

5

4

3

2

360

Use MMDDYYYY format.

Claimant’s registration number. 

$

$

EIN

$

346

Aviation-grade kerosene 369
Schedule 5 (Form 8849) (Rev. 2-2005) Page 2

Instructions

Section 4081(e) Claims

Section 4081(e) applies to gasoline, aviation gasoline, diesel

fuel, kerosene (other than aviation-grade kerosene), and

aviation-grade kerosene.

If two taxes were paid on the fuel for which the claim is

filed, then a claim for refund of the second tax may be made.

Claimant

Claim Requirement

Part I

Part II

Information to be Attached

1. A copy of the First Taxpayer’s Report that relates to the

fuel covered by each claim and

2. If the fuel covered by the claim was bought from

someone other than the first taxpayer, a copy of the

Statement of Subsequent Seller that the claimant received

with respect to that fuel.

How To File

Section references are to the Internal Revenue Code.

Purpose of Schedule

Example. Janet is a taxable fuel registrant that owns 10,000

gallons of gasoline that is being transported on a vessel in

the United States. On June 1, 2005, Janet sells the gasoline

to Hazel, a person that is not a taxable fuel registrant. Janet

is liable for tax on this sale. Janet prepares a First Taxpayer’s

Report related to this sale and gives a copy of the report to

Hazel.

On June 4, 2005, Hazel sells the same gallons of gasoline

to Caroline, a taxable fuel registrant. Hazel also gives

Caroline a copy of Janet’s First Taxpayer’s Report and a

Statement of Subsequent Seller. On June 9, 2005, the

gasoline is removed from a terminal at the rack. Caroline is

the position holder of the gasoline at the time of the removal

and thus is liable for tax on the removal. Caroline pays this

tax to the government.

After Caroline has filed a return of this second tax, Caroline

files Form 8849 and Schedule 5 for a refund for the second

tax and includes a copy of the First Taxpayer’s Report and

Statement of Subsequent Seller. In Part I of Schedule 5,

Caroline enters “1840.00” in column 1(a). In Part II, Caroline

enters “1” in column (c); “06092005” in column (d);

“10000.00” in column (e); and “1840.00” in column (f).

A person who paid the second tax to the government uses

Schedule 5 to make a claim for refund.

The person who paid the second tax to the government is

the only person eligible to make this claim.

Generally, the claim must be filed within 3 years from the

time the return for the second tax was filed or 2 years from

the time the second tax was paid to the government,

whichever is later.

For each type of fuel, enter the total of all amounts from

column (f), Part II.

For each payment of a second tax, complete all the

information required.

Attach Schedule 5 to Form 8849. On the envelope write

“Section 4081(e) Claim” and mail to the IRS at the address

under Where To File in the Form 8849 instructions.

Total Refund

Add all amounts in column (a) and enter the result in the

total refund box at the top of the Schedule.

The First Taxpayer’s Report and Statement of Subsequent

Seller must contain all the information as shown in Model

Certificates A and B in Appendix B of Pub. 510.