Free DR-191 - Florida

Application for Aviation Fuel Refund Air Carriers

DR-191 R. 07/06

For the Quarter Ending:

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** Your refund application will be rejected if fields in red are not completed in full.

Fill in Name of applicant/payee: Mailing street address: Mailing city, state, ZIP: Location street address: Location city, state, ZIP: Business telephone number (include area code): Fax number (include area code optional): FAC number: ­ ­ ­ ­ UT number: Federal employer identification number: ­ Computation of Refund 1. 2. 3. 4. Total Florida wages paid during the quarter (per Form UCT-6) Multiply Line 1 by .006 Amount of fuel tax paid in Florida (enter total tax paid for quarter from Schedule 1A) Amount of refund (enter the smaller amount of Line 2 or Line 3 above) E-mail address (optional):

$ $ $ $

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Under penalty of perjury I swear or affirm that this application has been examined by me and is true and correct for the period stated and is made in good faith pursuant to Chapter 206, Florida Statutes, and the regulations issued under the authority thereof. Sign and date this form.

Signature of Applicant/representative:

Date:

Print Name:

Title:

Important - A Florida Department of Revenue Power of Attorney (Form DR-835) must be properly executed and included if the refund request is submitted by the applicant's representative. Representative's phone number:
Area Code

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Phone number

Mail application to:

Refund Subprocess Florida Department of Revenue PO Box 6490 Tallahassee FL 32314-6490 Fax: 850-410-2526

General Instructions
Computation of Refund I. Line 1. Total gross wages paid for the quarter as reported on the Employer's Quarterly Tax Report - Florida Department of Revenue (Form UCT-6). Attach a copy of the UCT-6 covering the period stated. Line 2. Section 206.9855, Florida Statutes, provides for a refund not to exceed 0.6 percent of wages paid to employees based in Florida. Line 3. Enter the total amount of tax paid on aviation fuel from column six Schedule 1A. Line 4. Enter the smaller amount of line 2 or line 3. The refund shall not exceed the amount of tax paid to the state. II. Claim must be filed quarterly, no later than the last day of the month immediately following the end of the quarter. The filing date may be extended one additional month only if a justified excuse is submitted in writing and the prior quarter's application was filed timely.
Purchases Made During January, February, and March April, May, and June July, August, and September October, November, and December Claims Must Be Filed By* April 30 July 31 October 31 January 31 With A Written ExcuseNo Later Than May 31 August 31 November 30 February 28

DR-191 R. 07/06 Page 2

III. The Department will pay interest on refunds of this tax if the refund has not been paid or credited within 90 days of receipt of a complete application for refund. A complete application will contain documentation establishing the overpayment. Interest paid by the Department will be computed beginning on the 91st day based upon a statutory floating interest rate that may not exceed 11%. The interest provisions do not apply for refund applications filed prior to January 1, 2000, unless the claim is still pending as of July 1, 2000. Schedule of Purchases of Tax-Paid Aviation Fuel (Schedule 1A) IV. The Schedule of Purchases provides a detail in support of the amount of fuel purchased. Failure to provide all information required under columns one through six of this detail will result in a reduction or denial of your refund. If additional copies of schedules are necessary, photocopy as many copies as are needed to provide the required information. A management report from a third party may substitute for the detail required on the Schedule of Purchases (1A). However, the fuel management report must be in the same format and provide the same information as required on the Schedule of Purchases (1A), with the exception of column 2. List all suppliers, date received, invoice number, gallons, and amount of aviation fuel tax paid at 6.9 cents per gallon. Enter total amount of tax paid on Line 3 Part I.

*An amended claim for a prior quarter must be received by the current quarter's deadline. Example: An amended March quarterly application must be submitted by July 31.

For Information, Forms, and Online Filing
Online Refund Status Inquiry You can view the current status of a refund application by accessing the Department's website at http://www.myflorida.com/dor/eservices/ other/refunds/status/ Information and forms are available on our Internet site at www.myflorida.com/dor To speak with a Department of Revenue representative, call Taxpayer Services, Monday through Friday, 8 a.m. to 7 p.m., ET, at 800-352-3671 or 850-488-6800. Persons with hearing or speech impairments may call the TDD line at 800-367-8331 or 850-922-1115. Need information regarding Unemployment Tax? Contact the Florida Department of Revenue Unemployment Tax and Employer Information Center at 800-482-8293. To receive forms by mail: · Order multiple copies of forms from our Internet site at www.myflorida.com/dor/forms or · Fax form requests to the DOR Distribution Center at 850-922-2208 or · Mail form requests to: Distribution Center Florida Department of Revenue 168A Blountstown Hwy Tallahassee FL 32304-2702

If you need additional blank schedules, photocopy this page. (2) Supplier FEIN Date Received Gallons Invoiced Fuel Tax Paid (3) (4) (5)

Schedule 1A: Purchases of Tax-Paid Aviation Fuel
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(1)

Name of Supplier

Totals

Th is pa ge le ft bl an k in te nt io

na lly .
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