Fillable Form Au-736 - Motor Vehicle Fuels Tax Refund Claim

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Form AU-736

Department of Revenue Services

Fuel Type

Excise Taxes Unit

Motor Vehicle Fuels Tax Refund Claim

Diesel

Motor Vehicle Fuels

25 Sigourney Street

(Gasoline - Gasohol)

Motor Bus, Taxicab, & Livery.

Hartford CT 06106-5032

Claim Type

You must check the appropriate fuel type and claim type box on the right.

Refund claims must be filed on or before May 31, 2007, for fuel used during

Motor

Taxicab

Livery

(Rev. 07/06)

calendar year 2006. Complete this refund claim in blue or black ink only.

Bus

Name of Claimant (Type or print)

Period of Claim in Calendar Year

For DRS Use Only

Audit Number

2006

____/____ through ____/____

Claim Number

Voucher Number

Telephone Number

CT Tax Registration Number

Refund Gallons

(

)

Number and Street

FEIN

City or Town

SSN

Refund

State

ZIP+4

Due On or Before

Reviewed By

Date

May 31, 2007

Approved By

Date

Type of Business

Location of Records (if different from above)

Schedule A

Statement of Motor Vehicle Fuel Purchases. Receipts must be attached.

Date

Name of Supplier

Gallons of Fuel

Date

Name of Supplier

Gallons of Fuel

Total

(Round to the nearest whole gallon.)

Motor bus companies must attach a copy of their certificate of public convenience and necessity issued under Chapter 244 of the

Connecticut General Statutes with each claim filed.

Taxicab operators must attach a copy of their certificate of public convenience and necessity issued under Chapter 244a of the

Connecticut General Statutes with each claim filed.

Livery service operators (except motor buses) must attach a copy of their permit issued under Chapter 244b of the Connecticut

General Statutes with each claim filed. Livery service vehicles (except motor buses) are refunded at half the motor vehicle fuels tax rate.

Schedule B

Computation of net refund.

Total operating miles

(Includes total miles traveled in and out of Connecticut by motor buses or taxicabs

owned, leased, or borrowed, including charters.)

Enter the

Out-of-state mileage

out-of-state mileage.

Total - miles operated on Connecticut roads (Subtract Line 2 from Line 1.)

Percent of miles traveled on Connecticut roads (Divide Line 3 by Line 1 - carry to .0001.)

Total gallons of fuel used

(Include actual gallons of fuel used for all purposes.)

Fuel used other than in operation of motor buses, taxicabs, or livery.

(Includes fuel used for cleaning, operation of non-highway equipment, and motor

vehicles other than motor buses, taxicabs, or livery.)

Net operating gallons used exclusively in motor buses, taxicabs, or livery (Subtract Line 6 from Line 5.)

Gallons used to operate motor buses, taxicabs, or livery on Connecticut roads (Multiply Line 7 by Line 4.)

.00

Tax Refund Claimed (Multiply Line 8 by _____ per gallon. (See refund rate table on reverse side for appropriate rate.)

Declaration: I declare under penalty of law that I have examined this return (including any accompanying schedules and statements) and, to the best of my knowledge and belief, it is

true, complete, and correct. I understand the penalty for willfully delivering a false return or document to Department of Revenue Services (DRS) is a fine of not more than $5,000, or

imprisonment for not more than five years, or both. The declaration of a paid preparer other than the taxpayer is based on all information of which the preparer has any knowledge.

Taxpayer Signature

Title

Date

Print Taxpayer Name

Telephone Number

Date

Print Preparer Name

Preparer’s Address

Preparer’s SSN or PTIN