Fillable FUELS TAX REFUND APPLICATION (Virginia Department of Motor Vehicles)

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FUELS TAX REFUND APPLICATION (Virginia Department of Motor Vehicles)

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TS 219 (04/25/2014)
CERTIFICATION
FUELS TAX REFUND APPLICATION
EXPORTS
Purpose: Use this form to apply for a fuels tax refund on fuel purchased in bulk in Virginia and exported to another state.
Instructions: Follow the instructions on the reverse side of this form. Mail the completed application to DMV, Tax Services Refund Section,
P.O. Box 27422, Richmond, VA 23269-7422. Incomplete applications may not be processed.
APPLICANT INFORMATION
REFUND CLAIM PERIOD
BEGIN DATE
END DATE
SOCIAL SECURITY NUMBER OR FEIN
ADDRESS CITY ZIP CODE
EMAIL
PURCHASED/EXPORTED FUEL INFORMATION
GASOLINE DIESEL AVIATION OTHER
AUTHORIZED SIGNATURE
DATE (mm/dd/yyyy)
TITLE
NAME (print)
I certify and affirm that all information presented in this form is true and correct, that any documents I have presented to DMV are genuine,
and that the information included in all supporting documentation is true and accurate. I make this certification and affirmation under
penalty of perjury and I understand that knowingly making a false statement or representation on this form is a criminal violation.
DYED DIESEL
APPLICANT FULL LEGAL NAME(print) (last) (first) (mi) (suffix)
DATE SHIPPED SELLER NAME FUEL TYPE FUEL ORIGIN DESTINATION
DOCUMENT
NUMBER
BILLED
GALLONS
DIVERSION NUMBER
(if applicable)
TOTAL GALLONS PER FUEL TYPE
TELEPHONE NUMBER FAX NUMBER
STATE
REFUND CODE/GALLONS REFUNDED
DMV USE ONLY
Go Green! Save Paper!
Click here to reqister as a new customer and/or submit this application online.
Effective July 1, 2013, tax rates for fuel may change every six months. DMV calculates refunds based on the tax rate in effect at the time of fuel purchase
or shipment.
( )
( )
TS 219 (04/25/2014)
Receipts, tickets, invoices or bills of lading must be dated within the 12 month period preceding the date DMV receives your application. Invoices/tickets/
receipts must meet the following requirements must:
• include the seller's name and location address
• show the purchaser's name and the destination address of the fuel
• include the date of purchase, number of gallons, type of fuel and the rate/amount of the Virginia Fuels Taxes paid/charged
• indicate the bill of lading number and the diversion number if applicable
INSTRUCTIONS
GENERAL INFORMATION
To submit this application online use DMV's website, www.dmvNOW.com. - click "Online Services" - scroll to "Payments and Refunds" - scroll to "Fuels
Tax Refund" and, .
- click "Logon" to access your account and submit your refund application or,
- click "Register for MyFuels Tax Refund Account" to establish "Customer Registration" (a new account) and submit your refund application.
To complete and mail this application, continue to follow the instructions below.
APPLICANT INFORMATION
Complete Applicant Information.
PURCHASED/EXPORTED FUEL INFORMATION
Complete a row for each load of fuel exported out of Virginia to another state.
If the original destination of the fuel was changed you are required by law to report this transaction to a Diversion Registry to be assigned a diversion
number. Enter this diversion number. DMV will verify the diversion number with the fuel type, gallons, date and original destination. Any discrepancy
with the reported information can result in delays or a denial of your refund.
TOTAL GALLONS PER FUEL TYPE
Calculate and enter the total gallons exported for each type of fuel.
NOTE: Effective July 1, 2013, tax rates for fuel may change every six months. DMV calculates refunds based on the tax rate in effect at the
time of fuel purchase or shipment.
CERTIFICATION
Read and complete the Certification section.
Refunds will not be processed without a signed certification.
FINALIZE
Mail completed application and supporting documents to DMV Tax Services Refund Section, P.O.Box 27422, Richmond, Virginia 23269-7422.
The postmark date on your mailed application is recorded as the date DMV received your application.
Note: First time refund applicants must include all invoices/tickets/receipts that support their refund claim.
INVOICE/TICKET/RECEIPT REQUIREMENTS
RECORD KEEPING
Retain supporting documents for 4 years from the fuel purchase date. You may be requested to provide such documentation to DMV at any time during this 4
year period. Failure to provide the requested documentation will result in the denial or reversal of your refund.
DMV CONTACT INFORMATION
DMV DIRECT: (804) 497-7100 TTY (Deaf or hearing impaired only): 1-800-272-9268
Hours: Monday through Friday, 8:00 am to 5:00 pm, Saturday 8:00 am to 12:00 pm
SECURE EMAIL: www.dmvNOW.com, Home page click "contact Us", scroll down to "Email", click "Secure Online Form"
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FUELS TAX REFUND APPLICATION (Virginia Department of Motor Vehicles)

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Completed 2 November 2020

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