Form MDT-ADM-014 "Off-Road Refund of Montana Diesel and/or Gasoline Tax Application" - Montana

What Is Form MDT-ADM-014?

This is a legal form that was released by the Montana Department of Transportation - a government authority operating within Montana. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2019;
  • 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-014 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-014 "Off-Road Refund of Montana Diesel and/or Gasoline Tax Application" - Montana

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PO Box 8019
Montana Department of Transportation
Helena, MT 59604-8019
Phone: (406) 444-7664
Off-Road Refund of Montana
Fax (406) 444-5411
TTY: (406) 444-7696
MDT-ADM-014
Rev. 12/19
Diesel and/or Gasoline Tax Application
mdtfueltaxrefund@mt.gov
Page 1 of 3
www.mdt.mt.gov
Time period for Refund:
To:
S-Corp
General Partnership
Individual
Sole Proprietorship
Estate/Trust
C-Corp
Limited Partnership
Individual LLC
Partnership LLC
Corp LLC
Applicant Information
Name (Last, First, MI) or Trade Name:
Tax ID#:
SSN:
-OR-
Mailing Address:
How is fuel used?
City:
State:
Zip + 4:
Phone:
Requested Amounts
Gasoline Total
Diesel Total
Total Refund
+
=
$0.00
$0.00
$0.00
Applicant's Signature
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
Paid Preparer's Information
Preparer's Name
Firm's Name
Preparer Address
Phone
Date
Preparer Signature
Check the box if you do not want the Department of Transportation to discuss this return with the preparer above.
FOR OFFICE USE ONLY
Date Entered/Processed:
File Location:
Postmark Date:
PO Box 8019
Montana Department of Transportation
Helena, MT 59604-8019
Phone: (406) 444-7664
Off-Road Refund of Montana
Fax (406) 444-5411
TTY: (406) 444-7696
MDT-ADM-014
Rev. 12/19
Diesel and/or Gasoline Tax Application
mdtfueltaxrefund@mt.gov
Page 1 of 3
www.mdt.mt.gov
Time period for Refund:
To:
S-Corp
General Partnership
Individual
Sole Proprietorship
Estate/Trust
C-Corp
Limited Partnership
Individual LLC
Partnership LLC
Corp LLC
Applicant Information
Name (Last, First, MI) or Trade Name:
Tax ID#:
SSN:
-OR-
Mailing Address:
How is fuel used?
City:
State:
Zip + 4:
Phone:
Requested Amounts
Gasoline Total
Diesel Total
Total Refund
+
=
$0.00
$0.00
$0.00
Applicant's Signature
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
Paid Preparer's Information
Preparer's Name
Firm's Name
Preparer Address
Phone
Date
Preparer Signature
Check the box if you do not want the Department of Transportation to discuss this return with the preparer above.
FOR OFFICE USE ONLY
Date Entered/Processed:
File Location:
Postmark Date:
PO Box 8019
Montana Department of Transportation
Helena, MT 59604-8019
Phone: (406) 444-7664
Off-Road Refund of Montana
Fax (406) 444-5411
TTY: (406) 444-7696
MDT-ADM-014
Rev. 12/19
Diesel and/or Gasoline Tax Application
mdtfueltaxrefund@mt.gov
Page 2 of 3
www.mdt.mt.gov
Off-Road Refund
Applicant Name:
Bulk Storage Reconciliation
Undyed Diesel
Undyed Diesel
Gasoline Gallons
Gasoline Gallons
Gallons Prior to
Gallons 7/1/19 to
Prior to 7/1/19
7/1/19 to Present
7/1/19
Present
a) Beginning Inventory
b) Received into Storage (Bulk Gallons Purchased)
c) Total Inventory
d) Ending Inventory: (Gallons remaining in storage)
e) Total Fuel Dispensed:
f) Portion of line (e) dispensed into vehicles
g) Portion of line (e) dispensed into equipment
Refund Computation
1 Total miles traveled in all jurisdictions
2 Total gallons dispensed from bulk storage in vehicles
3 Total fuel placed in vehicles at the pump
4 Total gallons used in vehicles
5 Average miles per gallon…(Divide line 1 by line 4)
0
0
0
0
6 Total miles traveled on public roads in Montana
7 Total miles traveled off-road in Montana
8 Gallons used off-road in Montana
0
0
0
0
9 Total gallons disbursed from bulk storage into equipment
10 Total gallons placed into equipment at the pump
11 Total gallons placed into equipment on Public Road Projects
Total MT taxed gallons subject to refund
12
(lines 8 + line 9 + line 10 - line 11)
0
0
0
0
13 Tax paid per gallon
0.315
0.32
0.2925
0.2945
14 Amount of Refund (line 12 * line 13)
0
0
0
0
PO Box 8019
Montana Department of Transportation
Helena, MT 59604-8019
Phone: (406) 444-7664
Off-Road Refund Application
Fax (406) 444-5411
TTY: (406) 444-7696
MDT-ADM-014
Rev. 06/19
Refund of Montana Diesel or Gasoline Tax
mdtfueltaxrefund@mt.gov
Page 3 of 3
www.mdt.mt.gov
Applicants Name:
Fuel Purchased Prior to 7/1/19 Itemized Listing
List all bulk storage and Keylock/Cardtrol Purchases
Gasoline
Undyed Diesel
ATTACH ORIGINAL INVOICES
Prior to 7/1/19
Prior to 7/1/19
MT Taxed
MT Taxed
MT Taxed
MT Taxed
Gallons at the
Gallons at the
Gallons at the
Gallons at the
Pump
MT Taxed Bulk
Pump
Pump
MT Taxed Bulk
Pump
Placed in
Date of
Invoice
Gallons
Placed in
Placed in
Gallons
Placed in
Vehicle
Purchase
Number
Dealer
City
State
Purchased
Vehicle
Equipment
Purchased
Equipment
Columns Total
Fuel Purchased After 7/1/19 to Present Itemized Listing
List all bulk storage and Keylock/Cardtrol Purchases
Gasoline
Undyed Diesel
ATTACH ORIGINAL INVOICES
7/1/19 to Present
7/1/19 to Present
MT Taxed
MT Taxed
MT Taxed
MT Taxed
Gallons at the
Gallons at the
Gallons at the
Gallons at the
Pump
Pump
MT Taxed Bulk
Pump
MT Taxed Bulk
Pump
Placed in
Placed in
Date of
Invoice
Gallons
Placed in
Gallons
Placed in
Vehicle
Vehicle
Purchase
Number
Dealer
City
State
Purchased
Equipment
Purchased
Equipment
Columns Total
Page of 3