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

(July 1999)

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) Total amount of refund

(Form 8849)

EIN or SSN

(b)

CRN

For Privacy Act and Paperwork Reduction Act Notice, see Form 8849 instructions. Cat. No. 27453B Schedule 5 (Form 8849) (7-99)

301

307

Kerosene

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

(c) Type of fuel

(Enter line number

from Part I.)

(d)

Date second tax liability incurred

(e) Gallons of fuel claimed (f) Amount of second tax paid

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 312

2 10% gasohol

303

Enter whole gal. only.

Do not use commas or $ signs.

Dollars Cents

Do not use commas or $ signs.

Dollars Cents

Use MMDDYYYY format.
Schedule 5 (Form 8849) (7-99) 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. The person who paid the second tax to the

government is the only person eligible to make this claim.

Claim requirement. 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.

Part I. For each type of fuel, enter the total of all amounts

from column (f), Part II.

Part II. For each payment of a second tax, complete all the

information required.

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. 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.

Section references are to the Internal Revenue Code.

Purpose. A person who paid the second tax to the

government uses Schedule 5 to make a claim for refund.

Gallons of fuel claimed. Enter the amount to the nearest

whole gallon. See How To Round in the Form 8849

instructions.

Schedule 5 (Form 8849) (7-99)

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, 1999, 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, 1999, 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, 1999, 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” in the dollars column of line 1(a). In

Part II, Charlie enters “1” in column (c); “06091999” in

column (d); “10000” in column (e); and “1840” in column (f).