Fuel expense refund form

If, for some reason, you have to pay for fuel out of your own pocket (like when your fuel card isn’t working), you may be eligible for a refund from KBC Autolease Luxembourg, provided you:

Have a contract lease vehicle with fuel included in the charge you pay
Bought the fuel less than six months ago
Submit no more than three fuel expense claims per form

1Particulars

Vehicle registration plate

Company

Driver's first name

Driver's surname

Street

Number

Postal code

Town/City

E-mail address

2Account for making the refund

Name of account holder

IBAN

BIC

3Fill-up details

Fill-up 1

Date when you filled up your tank

Number of litres

Amount in euros incl. VAT

Number of kilometres

Attach filling station receipt

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Fill-up 2

Date when you filled up your tank

Number of litres

Amount in euros incl. VAT

Number of kilometres

Attach filling station receipt

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Fill-up 3

Date when you filled up your tank

Number of litres

Amount in euros incl. VAT

Number of kilometres

Attach filling station receipt

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Fill-up 4

Date when you filled up your tank

Number of litres

Amount in euros incl. VAT

Number of kilometres

Attach filling station receipt

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Fill-up 5

Date when you filled up your tank

Number of litres

Amount in euros incl. VAT

Number of kilometres

Attach filling station receipt

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Fill-up 6

Date when you filled up your tank

Number of litres

Amount in euros incl. VAT

Number of kilometres

Attach filling station receipt

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Fill-up 7

Date when you filled up your tank

Number of litres

Amount in euros incl. VAT

Number of kilometres

Attach filling station receipt

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Fill-up 8

Date when you filled up your tank

Number of litres

Amount in euros incl. VAT

Number of kilometres

Attach filling station receipt

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Fill-up 9

Date when you filled up your tank

Number of litres

Amount in euros incl. VAT

Number of kilometres

Attach filling station receipt

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Fill-up 10

Date when you filled up your tank

Number of litres

Amount in euros incl. VAT

Number of kilometres

Attach filling station receipt

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Total refund claimed

KBC Autolease aims to process your personal data in a manner that is lawful, appropriate and transparent. Further details about how we process and share your personal data are set out in our privacy statement. It explains your rights and how you can exercise them. Our privacy statement is available at www.kbclease.lu/privacy, at your branch or from your intermediary and is regularly revised.