Fillable 96-0490 Tribal Member Refund Application

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96-0490 Tribal Member Refund Application

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The 96-0490 Tribal Member Refund Application form is 1 page long and contains:

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Country of origin: US
File type: PDF

U.S.A. forms for Arizona Department of Transportation

BROWSE ARIZONA DEPARTMENT OF TRANSPORTATION (AZ) FORMS

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Mail Drop 521M
Fuel Tax Refund Compliance Unit
Arizona Department of Transportation
PO Box 2100
Phoenix AZ 85001-2100
Checks are now being mailed directly from the Arizona Department of Administration and we are no longer able to attach a copy of the refund
application to the check. Please keep a copy of your application for your records.
Refund Period Beginning Date
Refund Period Ending Date
Applicant Name (as shown on enrollment card)
Tribal Enrollment Number
Refund Account Number
G –
Residence Address (physical location on the reservation)
Refund Mailing Address
Check if changed
State
Zip
Tribal Name
Applicant Phone and/or Email
This fuel tax exemption applies to motor vehicle fuel or use fuel that is:
• Sold within the boundaries of the tribal reservation
• Sold to the enrolled member of the tribe indicated above, who is living on the reservation
• Used by the enrolled member for the member’s own benefit
The exemption does not apply to use fuel used to operate motor vehicles for a commercial purpose on the highways of this
state outside the reservation.
Applications must be completed in full and mailed to the address above, and must be submitted within six months from the date
the fuel was purchased or invoiced. If the allowable claim is for less than $10, only one request may be submitted in a
consecutive six month period.
Attach a copy of purchase invoices/receipts for all gallons claimed, a copy of your vehicle registration, and a copy of your tribal
enrollment card. These documents must be submitted with this application.
Motor Vehicle Fuel
ADOT Use
Gallons Claimed *
Tax Rate
x $0.18
Refund Amount
NG
Use Fuel
Light Class and
Exempt Use Class
NL
Gallons Claimed *
x $0.18
Refund Amount
Bulk Purchases
NH
Gallons Claimed *
x $0.26
Refund Amount
Total Refund Due
I certify that I am an enrolled member of the tribe, residing within the boundaries of the reservation, that the fuel was used for
my benefit and not used to operate motor vehicles for a commercial purpose on the highways of this state outside the
reservation. I further certify that the Arizona taxes have been paid on all the gallons claimed above and that the original,
unaltered invoices/receipts (and supporting documents) for the gallons claimed will be maintained for three years.
Applicant Signature
Date
ADOT Use
Compliance
Date Reviewed
Reviewer
Approved
Yes No
Approval Date
Postmark Date
Comments
Receipts
Date Entered
Entered By
QTRFR Verified
QTRFR Verified Date
Claim Number
Comments
TRIBAL MEMBER
REFUND APPLICATION
* Round to whole gallons.
• Complete online or in black ink
• Mail to the address above
96-0490 R06/20 azdot.gov
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96-0490 Tribal Member Refund Application

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Completed 25 June 2020

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