Section 40-17-103

Filing and form of claim for refund.

Claims for state gasoline tax refunds must be sworn to and be filed with the Commissioner of Revenue on forms to be prepared and distributed by the commissioner. Such forms must be substantially as follows:

CLAIM FOR REFUND OF STATE TAX ON GASOLINE USED ON A FARM FOR AGRICULTURAL PURPOSES.

1. Name __________________________

Address (Number and street or rural route) ____________________

(City, town, or post office) ______________ (Zone)

_______________ (State) _______________.

2. Total number of gallons of gasoline purchased after December 31, 19__, and before January 1, 19__, for farming purposes, and for which a claim has been filed for a refund of the federal tax on gasoline under Public Law 466, H.R. 8780, 84th Congress, Chapter 160, 2nd Session _____ gallons.

3. Total number of gallons of gasoline purchased after December 31, 19__, and before January 1, 19__, for propelling tractors which are used exclusively for agricultural purposes or for operating auxiliary engines attached to and made a part of any farm machinery _____ gallons.

4. The names and addresses of all retailers, refiners, or distributors from whom the gasoline for which the refund is being claimed was purchased, together with the dates and number of the invoices covering the total number of gallons of gasoline on which such refund is being claimed (attach sheet or enter on reverse side of this form).

5. Rate of refund of state tax (per gallon) __________ $.11.

6. Amount of refund claimed (line 3 multiplied by line 5) $______

I declare under the penalties of perjury that this claim has been examined by me and to the best of my knowledge and belief is true and correct, and that the number of gallons shown in item 5 does not exceed the total number of gallons of gasoline on which I am legally entitled, under the laws of this state, to a refund of a portion of the state tax paid.

Signed: _______________________

Date: _________________________

Sworn and subscribed before me this the _______ day of ___________, 19__.

(Acts 1957, No. 743, p. 1173, §4; Acts 1959, No. 416, p. 1104, §2; Acts 1969, No. 1155, p. 2160; Acts 1992, No. 92-203, p. 486, §6.)