North Dakota Office Of State Tax Commissioner Motor Fuel Tax Section Affidavit Of Lost Invoices
Please complete, sign and submit with claim for refund of fuel taxes. I, ________________________________________, certify that the original motor fuel purchase invoices listed
(Print Name of taxpayer filing claim)
below have been lost or cannot be supplied to me by the seller. Duplicate Copies Of The Invoices Are Attached To This Affidavit. ____________________________________ Taxpayer's Signature Subscribed and sworn to before me this ____ day of ______________________________, 20 ____. (Notary Seal) ____________________________________ Notary Public Signature
Seller's Name ________________________________________________________________________ The seller certifies that the attached copies of motor fuel purchase invoices are the exact duplicates of the originals, that each invoice has been paid in full by the purchaser of the fuel, and that the tax has been remitted to the Tax Commissioner. Please verify that the applicable duplicate invoices are attached by listing them in the space provided below. If additional space is needed, continue the list on the reverse side of the form. If the invoice covers motor vehicle fuel and if the tax is not listed on the invoice as a separate item, please enter it in the space provided. If the invoice covers special fuels and if the tax is not listed as a separate item, please complete the price and tax information in the spaces provided. Invoice # ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ Date ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ Gallons ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ Price (Without Tax) $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ Tax $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________
____________________________________ Seller Signature Subscribed and sworn to before me this ____ day of ______________________________, 20 ____. (Notary Seal)
22934 (Revised 8-1995)
____________________________________ Notary Public Signature
Continuation of Invoice Listing
Invoice # ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________
Date ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________
Gallons ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________
Price (Without Tax) $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________
Tax $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ $_______________