2 copies and submit it to the tax office.
You can get paper at the tax office. I downloaded it from the website of the National Tax Agency.

As a rule the sample has been refueled at Chofu Aerodrome and has become Musashino tax office in principle. However, if you have received tax exemption special case approval, you will need to fill in the name of the tax office applying for the special case and declare it to the tax office that applied for the special case.
The place where you fill in and stamp is indicated in red letters.

There is 1 KL / 26,000 yen for the sample, but the tax rate of the aircraft fuel tax has been lowered. Please check with the tax office. 2011.6