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Affidavit Of Certification Of Tax Paid Invoices REF-1000A - Indiana
| Affidavit Of Certification Of Tax Paid Invoices Form. This is a Indiana form and can be used in Refund Fuel And Environmental Department Of Revenue Statewide . |
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Form REF-1000A State Form 48389 (R/ 02-02) Indiana Department of Revenue Compliance Division Affidavit of Certification of Tax Paid Invoices Name of Seller D/B/A Address City/Town FEIN Number Business Telephone Number ( ) The attached copies of (number of) Social Security Number State Zip Code R.R.M.C. Number E-mail Address (opitional) 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 (Circle One) Invoice # Date Gallons Diesel/ Gasoline (Circle One) D/G D/G D/G D/G D/G D/G D/G D/G Signed Subscribed and sworn to before me, this My commission expires: *Attach additional sheets if necessary. Title day of , 20 Notary Public American LegalNet, Inc. www.FormsWorkflow.com
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