form ga-110lMP State Form 24721 (R3 / 4-08) Indiana Department of Revenue Claim for Refund Sales Tax on Gasoline, Gasohol, & Special Fuel Dispensed through Stationary Metered Pumps in Indiana Name of Taxpayer Taxpayer Identification (TID) or Non-Profit Certification # Street or P.O. Box Social Security or Federal ID # City State Zip FHWA or IMCA # Describe Exempt Use of Gasoline, Gasohol, or Special Fuel and period for which you are filing a refund. Attach additional sheets (if necessary): Period: Type Fuel: Exempt Use: Period: Type Fuel: Exempt Use: ▼ PLEASE NOTE ▼ In order to complete this form, you will first need to obtain the current gasoline, gasohol, or fuel tax rate(s) from Departmental Notice #12.You may review Departmental Notice # 12 on our web site at: www.in.gov/dor/reference/notices/pdfs/dn12.pdf or by calling the Department at (317) 232-2339. Column A Note: Special fuels include diesel fuel, liquefied petroleum (LP), compressed natural gas (CNG), compressed methane, and propane. Column B Gasoline 1. Total gallons purchased for exempt use per receipts. Column C Gasohol gallons Special Fuel gallons gallons 2. Total purchase price. ............................................... . 3. Current Rate. (From Departmental Notice #12). ..... . . . . 4. Total state and federal excise tax included in sales. (Multiply Line 1 x Current Rate ).............................. 5. Taxable amount. (Subtract Line 4 from Line 2)........ 6. Total sales tax paid on exempt gallons for exempt purposes. (See chart to calculate amount).............. The person or organization representative signing this application hereby certifies that sales tax has been paid on the purchase of gasoline, gasohol, or special fuel through a stationary metered pump as shown by attached receipts, such fuel has been used for a purpose which is exempted in Section IC 6-2.5 of the State Gross Retail Sales Act, and no other claim for refund has been filed on purchases shown on the attached receipts. Signature of Applicant_ _____________________________________________________________ Telephone Number_____________________ Title_____________________________________________________________________________ Date_ _______________________________ ▼ Mail to: Indiana Department of Revenue 100 N. Senate Avenue, Room N203 Indianapolis, IN 46204 for departmental use only If disallowed or adjusted - Explain ▼ Total Amount of refund ▼ For assistance call (317) 232-2339, or you may send an e-mail through our web site by accessing: www.in.gov/dor/contact/email.html then select “sales tax” as your subject title. Warrant Number Tax Analyst Date supervisor/Administrator Date Account Claim Number Warrant Date User ID Number Special Signature on file American LegalNet, Inc. www.FormsWorkflow.com Instructions for Form GA-110LMP Please note: In order to complete this form, you will first need to obtain the current gasoline, gasohol, or fuel tax rate(s) from Departmental Notice #12. You may review Departmental Notice # 12 on our web site at: www.in.gov/dor/reference/notices/pdfs/dn12.pdf or by calling the Department at: (317) 232-2339. The following instructions are to assist you in completing Form GA-110LMP. The instructions are valid for this form only. Line 1. Total Gallons Purchased for Exempt Use - Enter the total number of gallons purchased for exempt use. You must attach an original Form STR-100 (Certification of Exempt Purchases of Gasoline & Special Fuel) or copies of each gasoline receipt. Line 2. Total Purchase Price - Enter the total amount paid for the gallons purchased on Line 1. Line 3. Current Rate - Locate the rate from Departmental Notice #12. If you do not have this Notice, you will need to obtain one before you can proceed. Enter the rate on Line 3. Line 4. Total State and Federal Excise Tax - Enter the amount of state and federal excise tax included in sales. Multiply Line 1 by the rate on Line 3. And enter the amount on Line 4. Line 5. Taxable Amount - Subtract the amount on Line 4 from the amount on Line 2 and enter the difference on Line 5. Line 6. Total Sales Tax Paid on Fuel Used for Exempt Purposes - Calculate the amount on Line 6 by using the chart below. Either multiply or divide the amount on Line 5 and enter the amount on Line 6. This will be the amount being claimed as a refund. Chart to Calculate Line 6 Dates How to Calculate 1999 through 11/30/02 Divide the amount(s) on Line 5 by 21 12/01/02 through 03/31/08 Multiply Line 5 by 5.66% (.0566) 04/01/08 forward Multiply Line 5 by 6.54% (.0654) Please note: If you are filing using different periods of time and rates for gasoline and sales, you must complete a different form for each period. Taxpayer Representatives must have a valid POA-1 (Power of Attorney Form) on file with the Department. If you do not have a POA-1 form, you may obtain one from our web site at: www.in.gov/dor/taxforms/pdfs/poa1.pdf If you have questions or need assistance please call (317) 232-2339, or you may send an e-mail through our web site by accessing: www.in.gov/dor/contact/email.html Additional GA-110LMP forms may be requested by calling our Form Order Line at (317) 615-2581, leaving the order on our voice mail. Or, download a GA-110LMP by visiting: www.in.gov/dor/taxforms/pdfs/ga-110lmp.pdf Mail completed form to: Indiana Department of Revenue Tax Administration / Support, Mail Stop #105 100 N. Senate Avenue, Room N203 Indianapolis, IN 46204 Retain a copy of the completed form for your records. American LegalNet, Inc. www.FormsWorkflow.com