Form MDT-ADM-012 "Heating Fuel Refund of Montana Diesel Tax Application" - Montana

What Is Form MDT-ADM-012?

This is a legal form that was released by the Montana Department of Transportation - a government authority operating within Montana. Check the official instructions before completing and submitting the form.

Form Details:

  • Released on September 1, 2021;
  • The latest edition provided by the Montana Department of Transportation;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form MDT-ADM-012 by clicking the link below or browse more documents and templates provided by the Montana Department of Transportation.

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Download Form MDT-ADM-012 "Heating Fuel Refund of Montana Diesel Tax Application" - Montana

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PO Box 8019
PO Box 8019
Montana Department of Transportation
Montana Department of Transportation
Helena, MT 59604-8019
Helena, MT 59604-8019
Phone: (406) 444-6030
Phone: (406) 444-6030
Heating Fuel Refund of
Heating Fuel Refund of
Fax (406) 444-5411
Fax (406) 444-5411
TTY: (406) 444-7696
TTY: (406) 444-7696
MDT-ADM-012
MDT-ADM-012
Rev. 09/21
Rev. 09/21
Montana Diesel Tax Application
Montana Diesel Tax Application
mdtfueltaxrefund@mt.gov
mdtfueltaxrefund@mt.gov
Page 1 of 2
Page 1 of 2
www.mdt.mt.gov
www.mdt.mt.gov
Time period for Refund:
To:
Applicant Information:
Name (Last, First, MI) or Trade Name:
SSN:
Fed ID#:
-OR-
Mailing Address:
Phone Number:
City:
State: Zip + 4:
Requested Amounts
Heating Fuel Only
Total Gallons
Total Refund
Purchase Dates
Tax Rate
from Page 2
Gallons X Rate
Prior To 7/1/21
0.2945
$0.00
7/1/21 to Present
0.2955
$0.00
Total Refund
$0.00
Preparer's Information
Preparer's Name
Preparer Address
Phone
Preparer Signature
Date
Check the box if you do not want the Department of Transportation to discuss this return with the preparer above.
I/We hereby declare and represent that the above and foregoing is a true and correct statement showing diesel and/or gasoline
purchased and entirely consumed by the applicant; that the invoices included are the original purchase invoices received at the time
of purchase and delivery; that said claim against the State of Montana is just and wholly unpaid.
Applicant Signature
Date
FOR OFFICE USE ONLY
File Location:
Date Entered into MFTR:
Postmark Date:
PO Box 8019
PO Box 8019
Montana Department of Transportation
Montana Department of Transportation
Helena, MT 59604-8019
Helena, MT 59604-8019
Phone: (406) 444-6030
Phone: (406) 444-6030
Heating Fuel Refund of
Heating Fuel Refund of
Fax (406) 444-5411
Fax (406) 444-5411
TTY: (406) 444-7696
TTY: (406) 444-7696
MDT-ADM-012
MDT-ADM-012
Rev. 09/21
Rev. 09/21
Montana Diesel Tax Application
Montana Diesel Tax Application
mdtfueltaxrefund@mt.gov
mdtfueltaxrefund@mt.gov
Page 1 of 2
Page 1 of 2
www.mdt.mt.gov
www.mdt.mt.gov
Time period for Refund:
To:
Applicant Information:
Name (Last, First, MI) or Trade Name:
SSN:
Fed ID#:
-OR-
Mailing Address:
Phone Number:
City:
State: Zip + 4:
Requested Amounts
Heating Fuel Only
Total Gallons
Total Refund
Purchase Dates
Tax Rate
from Page 2
Gallons X Rate
Prior To 7/1/21
0.2945
$0.00
7/1/21 to Present
0.2955
$0.00
Total Refund
$0.00
Preparer's Information
Preparer's Name
Preparer Address
Phone
Preparer Signature
Date
Check the box if you do not want the Department of Transportation to discuss this return with the preparer above.
I/We hereby declare and represent that the above and foregoing is a true and correct statement showing diesel and/or gasoline
purchased and entirely consumed by the applicant; that the invoices included are the original purchase invoices received at the time
of purchase and delivery; that said claim against the State of Montana is just and wholly unpaid.
Applicant Signature
Date
FOR OFFICE USE ONLY
File Location:
Date Entered into MFTR:
Postmark Date:
PO Box 8019
PO Box 8019
Montana Department of Transportation
Montana Department of Transportation
Helena, MT 59604-8019
Helena, MT 59604-8019
Phone: (406) 444-6030
Phone: (406) 444-6030
Heating Fuel Refund of
Heating Fuel Refund of
Fax (406) 444-5411
Fax (406) 444-5411
TTY: (406) 444-7696
TTY: (406) 444-7696
MDT-ADM-012
MDT-ADM-012
Rev. 09/21
Rev. 09/21
Montana Diesel Tax Application
Montana Diesel Tax Application
mdtfueltaxrefund@mt.gov
mdtfueltaxrefund@mt.gov
Page 2 of 2
Page 2 of 2
www.mdt.mt.gov
www.mdt.mt.gov
Heating Fuel Refund
List Tax Paid Purchases Only
Attach Original Invoices
Gallons
Name of dealer from whom purchase was made
Gallons
Date of
Purchased
Invoice Number
Purchased
Purchase
7/1/21 to
Prior to 7/1/21
Name
City
State
Present
Total Gallons By Date Period (Enter on Page 1)
Page of 2