Form MC045D "Fuel Tax Refund Request Form" - Nevada

What Is Form MC045D?

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

Form Details:

  • Released on April 1, 2019;
  • The latest edition provided by the Nevada Department of Motor Vehicles;
  • 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 MC045D by clicking the link below or browse more documents and templates provided by the Nevada Department of Motor Vehicles.

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Download Form MC045D "Fuel Tax Refund Request Form" - Nevada

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MOTOR CARRIER DIVISION
555 WRIGHT WAY
CARSON CITY, NV 89711-0600
(775) 684-4711
fax (775) 684-4619
dmvnv.com/mcforms.htm
For office use only
Fuel Tax Refund Request Form (MC045D)
Postmark Date
PART-1 IDENTIFYING INFORMATION:
/
/
/
/
Nevada Account Number
Period Beginning
Period Ending
Account Name
Federal Employer Identification Number (FEIN)
Business Mailing Address
City
State
Zip
Location of Records Address (if different from above)
Email Address
Contact Person (Name/Telephone Number)
Account Number(s) and Jurisdiction(s) Issued:
Registration / IRP
Special Fuel / IFTA
Supplier / Dealer
Non-Nevada based carriers must submit copies of their registrations with Nevada
Authority or copies of Nevada trip permits covering the time period of the refund request.
Total NV taxable gallons reported on your IFTA Return (If applicable)
Return Period(s) (must correspond with refund period)
Indicate type of fuel claimed for a refund (use a separate claim form for each fuel type):
Diesel
Biodiesel
Kerosene
LPG (Propane)
CNG
(Complete and attach Part 2 Special Fuel)
How was fuel purchased?
Bulk (Must complete bulk fuel information in Sec D)
Purchased at the pump (Must provide receipts)
Total Refund Requested:
Special Fuel (from Part 2)
Under penalties of perjury, I declare that, as taxpayer or preparer, I have examined this refund request form, including the documentation attached,
and to the best of my knowledge and belief, it is true, correct and complete. All refund claims are subject to audit.
Printed Name of Taxpayer
Printed Name of Preparer if other Than Taxpayer
Signature of Taxpayer
Signature of Preparer if other than taxpayer
Title
Title
(
)
(
)
Telephone
Date
Telephone
Date
MC045D (4/2019)
Page 1 of 5
MOTOR CARRIER DIVISION
555 WRIGHT WAY
CARSON CITY, NV 89711-0600
(775) 684-4711
fax (775) 684-4619
dmvnv.com/mcforms.htm
For office use only
Fuel Tax Refund Request Form (MC045D)
Postmark Date
PART-1 IDENTIFYING INFORMATION:
/
/
/
/
Nevada Account Number
Period Beginning
Period Ending
Account Name
Federal Employer Identification Number (FEIN)
Business Mailing Address
City
State
Zip
Location of Records Address (if different from above)
Email Address
Contact Person (Name/Telephone Number)
Account Number(s) and Jurisdiction(s) Issued:
Registration / IRP
Special Fuel / IFTA
Supplier / Dealer
Non-Nevada based carriers must submit copies of their registrations with Nevada
Authority or copies of Nevada trip permits covering the time period of the refund request.
Total NV taxable gallons reported on your IFTA Return (If applicable)
Return Period(s) (must correspond with refund period)
Indicate type of fuel claimed for a refund (use a separate claim form for each fuel type):
Diesel
Biodiesel
Kerosene
LPG (Propane)
CNG
(Complete and attach Part 2 Special Fuel)
How was fuel purchased?
Bulk (Must complete bulk fuel information in Sec D)
Purchased at the pump (Must provide receipts)
Total Refund Requested:
Special Fuel (from Part 2)
Under penalties of perjury, I declare that, as taxpayer or preparer, I have examined this refund request form, including the documentation attached,
and to the best of my knowledge and belief, it is true, correct and complete. All refund claims are subject to audit.
Printed Name of Taxpayer
Printed Name of Preparer if other Than Taxpayer
Signature of Taxpayer
Signature of Preparer if other than taxpayer
Title
Title
(
)
(
)
Telephone
Date
Telephone
Date
MC045D (4/2019)
Page 1 of 5
PART-2 SPECIAL FUELS (DIESEL, BIODIESEL, KEROSENE, CNG, OR LPG ONLY) See instructions for specific
PTO refund details.
Section A - Power Take-Offs (PTO) Refunds:
(Dept Use Only)
Unit/Vehicle Type – Equipment
Total Gals consumed in
PTO
%
PTO Gallons Claimed
Gallons Allowed
List (Section C) must be attached
Nevada by Unit Type
Allowed
Cement Mixer(s)
30%
Concrete Pumper(s)
30%
Mobile Crane(s)
30%
Drill Rig(s)
30%
Garbage,
Sanitation,
Refuse
Truck(s)
20%
Auxiliary
Pump
Truck(s)
for
cleaning sewers, septic, cesspools
20%
Sweeper Truck(s)
20%
*For all other PTO exemptions
Total Gals consumed in
PTO
%
PTO Gallons Claimed
(Dept Use Only)
Gallons Allowed
List Unit Type being claimed
Nevada by Unit Type
Allowed
10%
10%
10%
10%
10%
10%
10%
(Dept Use Only)
**For all GPS exemptions
Enter “PTO” gallons
Enter “PTO” gallons
Gallons Allowed
List Unit Type being claimed
consumed from GPS
consumed from GPS
Total Gallons Claimed this period
0
0
(Enter totals for each column)
(Enter this total on next page)
*Each Unit must be listed separately by Unit Type. Effective January 1, 2009, PTO allowance is 10% for all equipment types, unless
specifically identified in the chart. Total PTO Gallons Consumed cannot exceed the total number of Gallons available for PTO
consumption in Nevada.
** GPS Allowances must be pre-approved by the Department.
MC045D (4/2019)
Page 2 of 5
Section B: OTHER EXEMPT SPECIAL FUEL USE:
Enter Total Clear Special Fuel Gallons consumed by category: (Must be rounded to the nearest whole
gallon) See instructions for additional detail.
A. Non-Highway Equipment _____________
D. Reefer Unit w/separate tank ____________________
B. Home Heating ____________________
E. Off-Road Mile/Total used in Gallons ______________
0
C. Government ________________________
“Section B” (A – E) Subtotal: ______________________
Special Fuel Exemption Calculations:
0
Subtotal Section A: Power Take-Off Gallons CLAIMED:
_____________________
(Total from “PTO Gallons Claimed” column on page 2)
0
Subtotal Section B: Other Exempt Special Fuel Use Gallons: + _____________________
(Total A – E above)
0
TOTAL SPECIAL FUEL GALLONS REQUESTED:
= _____________________
(Enter total of Sections A + B for total SF gallons requested)
Diesel, Biodiesel,
LPG
CNG
Dept Use Only
Refund Calculations:
Kerosene
Total SF Gallons Requested
Tax Rate***
.2646
.0627
.2058
Total Refund Claim
$
$
$
Identify Attachments:
Equipment List (Attachment A)
Bulk Fuel Inventory List (Attachment B)
Original Fuel Receipts
Fuel Spreadsheet
Off-Road Mileage Log
Other ___________________
Other ___________________
For Department Use Only
Received by: ___________ Date: _________________ Returned for correction by: __________ Date: ____________
Processed by: ____________ Date: _____________ Amount of Refund: __________________
Attachments confirmed: Yes _______
No _________ By: _______
Notes: _________________________________
MC045D (4/2019)
Page 3 of 5
Attachment A - Equipment List
DESCRIPTION OF EQUIPMENT, MAKE,
PURPOSE FOR WHICH USED
LICENSE
PTO UNIT TYPE
HORSEPOWER, UNIT NUMBER
PLATE #
IE: Cement Mixer, Dump Truck, etc.
MC045D (4/2019)
Page 4 of 5
Attachment B - Bulk Fuel – Must be completed if bulk fuel is maintained.
Brief description of business operations: ________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Number of Bulk Fuel Tank(s) ________ Capacity of each tank ______________________________
(Please attach a bulk tank inventory sheet to correspond with this claim for each bulk tank)
Physical location of bulk fuel tank(s) ____________________________________________________
Are Tank(s) Metered?
Yes*
No
*If yes, are they located above ground?
Yes
No
Are bulk tank and fuel truck tank logs maintained with the number of gallons specified by equipment
number?
Yes
No
Are bulk tank inventories reconciled?
Yes*
No *If yes,
Daily
Monthly
Quarterly
Are odometer readings recorded for highway use vehicles?
Yes*
No
*If yes,
Daily
Monthly
Quarterly
Please list the suppliers from whom you purchase fuel________________________________________
_________________________________________________________________________________
Bulk Fuel Inventory – Please report in total Gallons by tank and fuel type.
Tank 1 – List Fuel Type
_____________
Tank 2 – List Fuel Type
______________
Beginning Inventory
_____________
Beginning Inventory
______________
Total Purchases
+ _____________
Total Purchases
+ ______________
Ending Inventory
- _____________
Ending Inventory
- ______________
Gain/Loss
- _____________
Gain/Loss
- ______________
Gallons Dispensed
= _____________
Gallons Dispensed
= ______________
Tank 3 – List Fuel Type
_____________
Tank 4 – List Fuel Type
______________
Beginning Inventory
_____________
Beginning Inventory
______________
Total Purchases
+ _____________
Total Purchases
+ ______________
Ending Inventory
- _____________
Ending Inventory
- ______________
Gain/Loss
- _____________
Gain/Loss
- ______________
Gallons Dispensed
= _____________
Gallons Dispensed
= ______________
Total Bulk Clear Diesel Fuel Dispensed ________________
MC045D (4/2019)
Page 5 of 5