BOE-770-DVW REV. 4 (4-03)
BOARD OF EQUALIZATION
BOARD USE ONLY
RA-B/A RR-QS EFF AUD FILE REG REF
STATE OF CALIFORNIA
DIESEL FUEL TAX CLAIM FOR REFUND - SALES TO ULTIMATE PURCHASERS
CLAIM PERIOD / / THROUGH / /
YOUR ACCOUNT NO.
BOARD OF EQUALIZATION FUEL TAXES DIVISION PO BOX 942879 SACRAMENTO, CA 94279-2050
READ INSTRUCTIONS BEFORE PREPARING
As an ultimate vendor of diesel fuel in California, you may use this form to file a claim for refund of tax you paid on undyed diesel fuel sold without the tax reimbursement to ultimate purchasers for use on a farm for farming purposes or for use in an exempt bus operation. Your claim must cover a period of not less than one week and total at least $200. If the refund due for one week's sales is less than $200, please wait to file this form until your refund totals at least $200, or include those sales in your periodic report/claim for refund (Form BOE-770-DV). Enter the beginning and ending dates of the period covered by this claim as mm/dd/yy in the box above.
CLAIM FOR REFUND
1. Tax-paid fuel sold for use on farms (enter from Schedule 13D) 2. Tax-paid fuel sold for use in exempt bus operations (enter from Schedule 13E) 3. Total whole gallons of tax-paid undyed diesel fuel to be refunded (add lines 1 and 2) 4. Tax rate 5. AMOUNT OF REFUND (multiply line 3 by line 4) If refund amount is less than $200, do not submit claim. 1. 2. 3. 4. 5. $
You may use this form to file a claim for refund of tax paid on undyed diesel fuel sold without the tax reimbursement to ultimate purchasers. Your claim must cover a period of not less than one week and total at least $200. The period covered by your claim can include more than one week's sales if necessary to reach the $200 minimum. You must submit completed Schedules 13D and 13E with your claim. You are required to file a periodic report (Form BOE-770-DV) with the State Board of Equalization, listing your diesel fuel receipts and disbursements of dyed diesel fuel. If you prefer, you may claim a refund on that report instead of filing this weekly claim form. You must file the periodic report whether or not you file separate weekly claims. NOTE: Even if you qualify to file weekly claim forms, any exempt sales to ultimate purchasers for the last week of the period must be claimed on the periodic report (Form BOE-770-DV). Refer to instructions and schedules with your monthly BOE-770-DV (Diesel Fuel Ultimate Vendor Report/Claim For Refund), for completing this claim for refund on undyed diesel fuel sold for use on a farm for farming purposes or in an exempt bus operation or for additional information, visit our website at the following address: http://www.boe.ca.gov/sptaxprog/spftdmfuels.htm 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 all ultimate purchasers for transactions covered by this claim, and that, to the best of my knowledge, all information on the certificates is true and correct.
YOUR SIGNATURE AND TITLE TELEPHONE NUMBER DATE