Form 8849

(Rev. April 1996) Claim for Refund of Excise Taxes OMB No. 1545-1420

Department of the Treasury

Internal Revenue Service © See separate instructions.

Name of claimant

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

City or town, state, and ZIP code

Please type or print

Taxpayer identification number

1 2 Total amount to be refunded

$

Type of excise tax return filed, if any (See instructions.)

720 2290

For Paperwork Reduction Act Notice, see separate instructions. Cat. No. 20027J Form 8849 (Rev. 4-96)

730

3 Gasoline Wholesale Distributors (See instructions.)

Claimant bought gasoline or gasohol at a price that included the excise

tax and sold it directly to a state or local government for its exclusive

use; directly to a nonprofit educational organization for its exclusive use;

as supplies for vessels or aircraft; for export; or for use in the production

of special fuels. 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.

Rate Gallons Amount of refund CRN

301

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

$.183

.129

.14142

.15222

Period of claim ©

5 Nontaxable Use of Gasohol (See instructions.)

Rate Gallons Amount of refund CRN

312

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

$.129

.14142

.15222

Nontaxable Use of Gasoline (See instructions.)

Rate Gallons Amount of refund

Off-highway business use $.183

4

CRN

301

Nontaxable Use of Undyed Diesel Fuel (Lines 6a, b, and c)

Sales by Registered Ultimate Vendors of Undyed Diesel Fuel (Line 6d)

Rate Gallons Amount of refund

$.243

6

CRN

303

.183

b

a

c

Heating oil

b Off-highway business use

a

c

.243

.243

.243

d

a

b

Claimant, a registered ultimate vendor, sold diesel fuel to

a state or local government for its exclusive use or for use

by the buyer on a farm for farming purposes. Claimant

obtained the required certificate from the buyer and has no

reason to believe any of the information in the certificate is

false. Caution: You must enter here the number of gallons

and the amount of refund or your claim will be delayed.

Also, see page 2 of the instructions.

Other nontaxable use

Other nontaxable use

%

Lines 6a, b, and c: Claimant has in its possession the name

and address of the person(s) who sold the diesel fuel to

the claimant and the date(s) of the purchase(s).

a

b

c

d %

Period of claim ©

Period of claim ©

Period of claim ©

%

Type of use

Type of use

Type of use

Claimant certifies that the diesel fuel did not contain visible evidence of dye. However, if any of the diesel fuel included in this claim did

contain visible evidence of dye, check the box and attach a detailed explanation

Telephone number

Month your income tax year ends

( )

%
Form 8849 (Rev. 4-96) Page 2

Period of claim ©

Printed on recycled paper

Gasohol Blenders

Percentage of alcohol in the gasohol Rate Gallons of gasoline CRN

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

10

302

Other Claims. See page 3 of the instructions.

Claimant has in its possession the name and address of the

person(s) who sold the diesel fuel to the claimant and the date(s)

of the purchase(s).

CRN

Diesel-powered trains

11

Rate Gallons

Certain intercity and local buses .17

305

*b

*a

*c

a

b

8

Special motor fuels (other than LPG or used in

intercity or local buses)

9

Nontaxable Use of Gasoline Used in Aviation (See instructions.)

Nontaxable Use of Aviation Fuel (other than gasoline)

$.183

Other nontaxable use

Used in commercial aviation (other than foreign

trade)

Used in commercial aviation (other than foreign

trade)

$.14

.183

7

Compressed natural gas (rate per thousand cubic feet) .4854

Rate Gallons Amount of refund CRN

Rate Gallons CRN

Rate Gallons CRN

304

307

310

Nontaxable Use of Special Fuels

*b

a

b

a

b

Liquified petroleum gas (LPG)

Special motor fuels used in intercity or local buses

.183

c .109

d

%

%

Period of claim ©

Period of claim ©

Period of claim ©

Use of Undyed Diesel Fuel—Train and Intercity

and Local Bus (See instructions.)

12

Period of claim ©

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.

Sign

Here © Signature Date © (Please type or print name.)

* These claim provisions have expired.

a Other nontaxable use

$.1875

Amount of refund

Amount of refund

Amount of refund

Amount of refund

MCF

Type of use

Type of use

Type of use

%

Claimant certifies that the diesel fuel did not contain visible evidence of dye. However, if any of the diesel fuel included in this claim did

contain visible evidence of dye, check the box and attach a detailed explanation

$.043