Form REF-1000A                   Indiana Department of Revenue                     Mail to:
          State Form 48389                Special Tax Division                        Indiana Department of Revenue
          (R2 / 5-13)                                                                 Special Tax Section
                           Affi davit of Certifi cation of Tax Paid Invoices            P.O. Box 1971
                                                                                      Indianapolis, IN  46206-1971
                                                                                      317-615-2552
Name of Seller

DBA

Address

City/Town                                            State                            Zip Code

FEIN Number                        Social Security Number              RRMC Number

Business Telephone Number                            Email Address (optional)

The attached copies of (number of)  _________ invoice(s) showing (name)  ________________________________ as 
purchaser represent sales of fuel on the dates shown on the invoices by the supplier whose name appears above.

Listed below are the invoice number(s), date(s), and gallonage of these purchases according to our records. (attach addi-
tional sheets if necessary)

Copies of all listed invoices are attached. These records are available for review at:

_______________________________________________________________________________________________

                                      Diesel/                                                                  Diesel/
Invoice                             Gasoline              Invoice                                              Gasoline 
Number        Date         Gallons  (Select One)          Number       Date           Gallons        (Circle One)

                                    □ Diesel                                                         □ Diesel
                                    □ Gasoline                                                       □ Gasoline

                                    □ Diesel                                                         □ Diesel
                                    □ Gasoline                                                       □ Gasoline

                                    □ Diesel                                                         □ Diesel
                                    □ Gasoline                                                       □ Gasoline

Seller’s Signature  ____________________________________       Title _________________________________

STATE OF _____________   )
  )
COUNTY OF ____________  ) SS:

Before me the undersigned, a Notary Public for ____________________ County, State of ______________, 
personally appeared ________________, and he being  first duly sworn by me upon his oath, says that the facts 
alleged in the foregoing instrument are true. Signed and sealed this ______ day of _______________, 20 _____.

                                                                  ____________________________________
                                                                                      (Signature) Notary Public

                                                                  ____________________________________
                                                                                      (Printed Name)

County of Residence: ________________________  My Commission Expires: __________________