Form Schedule 5 (Form 8 Schedule 5 (Form 8 Section 4081(e) Claims

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TREASURY/IRS AND OMB USE ONLY DRAFT
Schedule 5
(Form 8849)
(Rev. December 2025)
Department of the Treasury
Internal Revenue Service

Section 4081(e) and 6435 Claims

OMB No. 1545-1420

Attach to Form 8849. Do not file with any other schedule.
Go to www.irs.gov/Form8849 for instructions and the latest information.

Name as shown on Form 8849

EIN

Total claim (see instructions)

$
Claimant’s registration number

Part I

Claim for Refund or Payment of Tax. Caution: Section 4081(e) claims are made on Schedule 5 by the person
that has filed Form 720 reporting and paying the tax claimed. Section 6435 claims are made on Schedule 5 by
the person that has removed previously taxed dyed diesel fuel or dyed kerosene from an approved terminal.
(a)
Amount of claim

1
2
3
4
5
6
7
8
9
10

Gasoline
Aviation gasoline
Diesel fuel
Kerosene
Diesel-water fuel emulsion
Dyed diesel fuel, dyed kerosene, and other exempt removals (for section 4081(e) claims)
Kerosene for use in aviation
Kerosene for use in commercial aviation (other than foreign trade)
Dyed diesel fuel (for section 6435 claims)
Dyed kerosene (for section 6435 claims)

(b)
CRN

362
324
360
346
309
303
369
355
472
473

Type of claim
Caution: Check only one per Schedule. See instructions for more information on making both section 4081(e) and 6435 claims.
Section 4081(e) claims (complete Part II)
Section 6435 claims (complete Part III)
Supporting Information Required for Section 4081(e) Claims. See instructions. If more space is needed, attach
Part II
separate sheets.
Claimant certifies that the amount of the second tax has not been included in the price of the fuel, and has not been
collected from the purchaser. Claimant has attached a copy of the First Taxpayer’s Report, and if applicable, a copy of
the Statement of Subsequent Seller.
(c) Type of fuel
Enter line number from
Part I.

(d)
Date second tax liability incurred
Use MMDDYYYY format.

(e)
Gallons of fuel claimed

For Privacy Act and Paperwork Reduction Act Notice, see Form 8849 instructions.

Cat. No. 27453B

(f)
Amount of second tax paid

Schedule 5 (Form 8849) (Rev. 12-2025) Created 9/9/25

DRAFT — DO NOT FILE

DRAFT — DO NOT FILE

Type of fuel

TREASURY/IRS AND OMB USE ONLY DRAFT
Page 2

Schedule 5 (Form 8849) (Rev. 12-2025)

Part III

Supporting Information Required for Section 6435 Claims. See instructions. If more space is needed, attach separate
sheets.
Claimant has attached a copy of the First Taxpayer’s Report, and if applicable, a copy of the Statement of Subsequent
Seller.
(h)
Date of removal of dyed fuel
Use MMDDYYYY format.

(i)
Gallons of fuel claimed

(j)
Amount of prior tax paid

DRAFT — DO NOT FILE

DRAFT — DO NOT FILE

(g) Type of fuel
Enter line number from
Part I.

Schedule 5 (Form 8849) (Rev. 12-2025)