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

(Rev. January 2002)

Schedule 5 Department of the Treasury—Internal Revenue Service

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. 1-2002)

362

324

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

6

7

4 5.7% gasohol

3 7.7% gasohol 375

2 10% gasohol

360

Use MMDDYYYY format.

Claimant’s registration number. 

$

$

EIN

$

359

376

346
Schedule 5 (Form 8849) (Rev. 1-2002) Page 2

Instructions

Section 4081(e) Claims

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

gasoline, diesel fuel, and 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. Acme 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, 2002, Acme sells the gasoline

to Bravo, a person that is not a taxable fuel registrant. Acme

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

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

Bravo.

On June 4, 2002, Bravo sells the same gallons of gasoline

to Charlie, a taxable fuel registrant. Bravo also gives Charlie

a copy of Acme’s First Taxpayer’s Report and a Statement of

Subsequent Seller. On June 9, 2002, the gasoline is removed

from a terminal at the rack. Charlie is the position holder of

the gasoline at the time of the removal and thus is liable for

tax on the removal. Charlie pays this tax to the government.

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

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,

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

enters “1” in column (c); “06092002” 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 report must contain all the information as shown in

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