Tax Rebate Agreement by fil14399


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									                                                                                      FUEL TAX REBATE AGREEMENT
     Tax and Revenue Administration                                                                                   The Fuel Tax Act
   This form is used when any fuel on which you are claiming a tax rebate was purchases in the name of another individual or company.




   Initial Purchaser of Fuel



              1. We hereby agree that the invoices submitted:

                         with this application, * period                        to                     ,*
                                                                  Start date            End date

                         within the period                         to                   , **
                                                    Start date             End date

                   (Mark the above option(s) with an "X", and then complete inserts as necessary)

                   In the name of                                                 represent fuel purchased
                                                Initial purchaser's name

                   on behalf of and consumed in the operations of                                                    .
                                                                                        Claimant's name

              2.                                  agrees not to use these invoices on a fuel tax rebate claim.
                         Initial purchaser

                               Initial purchaser's signature                    Claimant's signature

                                         Date                                           Date

     * Only invoices, statements, or receipts included with this particular application are subject to this particular agreement.
     ** Any invoices, statements, or receipts submitted by the claimant with this form will be subject to this agreement. It is
     the responsibility of the parties to the agreement to advise Alberta Finance and Enterprise - Tax and Revenue
     Administration of any changes to, or cancellation of, this agreement prior to the ending date. Without such notification,
     the agreement in its present form will be binding.
     Please submit the Fuel Tax Rebate Agreement (AT4911) with your application, if applicable.

AT4911 (Aug-09) Internet

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