Affidavit Of Certification Of Tax Paid Invoices
Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Affidavit Of Certification Of Tax Paid Invoices Form. This is a Indiana form and can be use in Department Of Revenue Statewide.
Loading PDF...
Tags: Affidavit Of Certification Of Tax Paid Invoices, REF-1000A, Indiana Statewide, Department Of Revenue
Indiana Department of Revenue
Compliance Division
Form REF-1000A
State Form 48389
(R/ 02-02)
Affidavit of Certification of Tax Paid Invoices
Name of Seller
D/B/A
Address
City/Town
State
FEIN Number
Social Security Number
Business Telephone Number
(
)
Zip Code
R.R.M.C. Number
E-mail Address (opitional)
The attached copies of (number of)
invoice(s) showing (name)
as purchaser represent sales of fuel on the dates shown on
the invoices by the supplier whose name appears above.
Listed below are invoice number(s), date(s), and gallonage of these purchases according to our records.*
Copies of all listed invoices are attached. These records are available for review at
.
.
Invoice #
Date
Gallons
Diesel/
Gasoline
Invoice #
Date
Gallons
Diesel/
Gasoline
(Circle One)
D/G
D/G
D/G
D/G
D/G
Subscribed and sworn to before me, this
D/G
D/G
Signed
(Circle One)
D/G
Title
day of
, 20
My commission expires:
*Attach additional sheets if necessary.
Notary Public
American LegalNet, Inc.
www.FormsWorkflow.com
