Free Claim for Refund on Nontaxable Sales and Exports of Diesel Fuel - California

BOE-770-DZ (S1) REV. 2 (4-03)

BOARD OF EQUALIZATION
BOARD USE ONLY
RA-B/A RR-QS YOUR ACCOUNT NO. EFF AUD FILE REG REF

STATE OF CALIFORNIA

CLAIM FOR REFUND ON NONTAXABLE SALES AND EXPORTS OF DIESEL FUEL
CLAIM PERIOD / / THROUGH / /

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BOARD OF EQUALIZATION FUEL TAXES DIVISION PO BOX 942879 SACRAMENTO CA 94279-2050

READ INSTRUCTIONS BEFORE PREPARING

You may use this form to file a claim for refund of tax paid on undyed diesel fuel exported for use outside the state, sold to the U.S. Government, sold to train operators for use in a diesel-powered train or for other off-highway use, or used in your operations for purposes other than propelling vehicles on the highway of this state. Enter the beginning and ending dates of the period covered by this claim as mm/dd/yy in the box above. REPORT OF DIESEL FUEL TRANSACTIONS 1. Undyed diesel fuel purchased in California tax-paid (enter from Schedule 1A) 2. Dyed and undyed diesel fuel purchased ex-tax for sale or use in California (enter from Schedule 2A) 1. 2.
REPORT WHOLE GALLONS ONLY

CLAIM FOR REFUND OF TAX-PAID DIESEL FUEL 3. Tax-paid fuel exported (enter from Schedule 13A) 4. Tax-paid fuel sold to the United States Government (enter from Schedule 13C) 5. Tax-paid fuel sold to train operators (enter from Schedule 13G) 3. 4. 5.

REPORT WHOLE GALLONS ONLY

6. Tax-paid fuel used in your operations for purposes other than to operate motor vehicles on-highway 6. 7. Total gallons of tax-paid diesel fuel to be refunded (add lines 3 through 6) 8. Tax rate 9. AMOUNT OF REFUND (multiply line 7 by line 8) 7. 8. 9. $

.18

CERTIFICATION I, the undersigned, certify that, to the best of my knowledge, all information on this claim and any accompanying documents is true, correct, and complete. I further certify that the diesel fuel covered by this claim did not show any visible evidence of dye, and that the diesel fuel tax was not included in the sales price of the diesel fuel covered by this claim and was not collected from the purchasers. In addition, I certify that I have in my possession valid exemption certificates from train operators for transactions covered by this claim, and that, to the best of my knowledge, all the information on the certificates is true and correct.

YOUR SIGNATURE AND TITLE

TELEPHONE NUMBER

DATE

CONTINUE

BOE-770-DZ (S3) REV. 2 (4-03)

STATE OF CALIFORNIA

RECEIPT SCHEDULE
(If additional space is needed, please photocopy the schedule before making entries.)
(a) COMPANY NAME (b) ACCOUNT NUMBER (c) SCHEDULE CODE (d) PRODUCT CODE

BOARD OF EQUALIZATION Page of

(e) MONTH/YEAR

(1) CARRIER NAME

(2) CARRIER FEIN

(3) MODE

(4) POINT OF
(TCN or State/Province)

ORIGIN

DESTINATION
(TCN or State/Province)

(5) ACQUIRED FROM (Seller's Name)

(6) SELLER'S FEIN

(7) DOCUMENT DATE

(8) DOCUMENT NUMBER

(9) NET GALLONS

(10) GROSS GALLONS

(11) BILLED GALLONS

TOTAL

BOE-770-DZ (S4) REV. 2 (4-03)

STATE OF CALIFORNIA

DISBURSEMENT SCHEDULE
(If additional space is needed, please photocopy the schedule before making entries.)
(a) COMPANY NAME (b) ACCOUNT NUMBER (c) SCHEDULE CODE (d) PRODUCT CODE

BOARD OF EQUALIZATION Page of

(e) MONTH/YEAR

(1) CARRIER NAME

(2) CARRIER FEIN

(3) MODE

(4) POINT OF
(TCN or State/Province)

(5) BUYER'S NAME

ORIGIN

DESTINATION
(TCN or State/Province)

(6) BUYER'S FEIN

(7) DOCUMENT DATE

(8) DOCUMENT NUMBER

(9) NET GALLONS

(10) GROSS GALLONS

(11) BILLED GALLONS

TOTAL

CLEAR

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