Form 8849

(Rev. January 1997) 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. 1-97)

730

3 Gasoline Wholesale Distributors

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

$.

.

.

.

Period of claim ©

5 Nontaxable Use of Gasohol

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

$.

.

.

Nontaxable Use of Gasoline

Rate Gallons Amount of refund

$.

4

CRN

301

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

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

Rate Gallons Amount of refund

$.

6

CRN

303

b

a

c

Heating oil

b

a

c

.

.

Claimant, a registered ultimate vendor, sold diesel fuel

for use by the buyer on a farm for farming purposes or to

a state or local government for its exclusive use. Claimant

obtained the required certificate from the buyer and has no

reason to believe any of the information in the certificate is

false. 

Nontaxable use

Other nontaxable use

%

Lines 6a and b: Claimant has the name and address of the

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

date(s) of the purchase(s) and if exported, the required proof

of export.

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. 

If any of the diesel fuel included in this claim did contain visible evidence of dye, attach a detailed explanation and check here ©

Telephone number

Month your income tax year ends

( )

%

Caution: Complete all applicable entries or your claim will be delayed.

Caution: You cannot make a claim for refund on lines 6a

or 6b for the tax paid on diesel fuel that you used on a farm

for farming purposes or on diesel fuel for the exclusive use

of a state or local government.
Form 8849 (Rev. 1-97) Page 2

Period of claim ©

Gasohol Blenders

CRN

Percentage of alcohol in the gasohol

Rate Gallons of gasoline

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 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 .

305

b

a

c

a

b

8

Special motor fuels

9

Nontaxable Use of Aviation Gasoline

Nontaxable Use of Aviation Fuel (other than gasoline)

$.

Other nontaxable use

Used in commercial aviation (other than foreign trade)

Used in commercial aviation (other than foreign trade)

$.

.

7

Compressed natural gas (rate per thousand cubic feet) .

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

Special motor fuels used in intercity or local buses .

c

%

Period of claim ©

Period of claim ©

Period of claim ©

Use of Undyed Diesel Fuel—Train and Intercity

and Local Bus

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.)

Other nontaxable use

a

$.

Amount of refund

Amount of refund

Amount of refund

Amount of refund

MCF

Type of use

Type of use

Type of use

%

$.

$.

.

.

%

%

Claimant bought gasoline taxed at the full rate and blended it with

alcohol to make gasohol. The gasohol was used or sold for use in a

trade or business. For each batch of gasohol, claimant has the

required information relating to the purchase of the gasoline and

alcohol used to make the gasohol and to support the amount

claimed.

%

.

Claimant certifies that the diesel fuel did not contain visible evidence of dye. 

If any of the diesel fuel included in this claim did contain visible evidence of dye, attach a detailed explanation and check here ©