Form Au-741 - Motor Vehicle Fuels Tax Refund Claim - 2006
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1Department of Revenue Services
Form AU-741
Reset Form
Excise Taxes Unit
Fuel Type
Motor Vehicle Fuels Tax Refund Claim
25 Sigourney Street
Diesel
Motor Vehicle Fuels
(Gasoline - Gasohol)
Hartford CT 06106-5032
Commuter Vans
You must check the appropriate fuel type box on the right. Refund claims
Claim Type
must be filed on or before May 31, 2007, for fuel used during calendar year
(Rev. 07/06)
Commuter Vans
2006. Complete this refund claim in blue or black ink only.
Name of Claimant (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
Type of Business
Location of Records (if different from above)
Approved By
Date
Owner or Lessee of Vehicle
Vehicle Registration Number
Average Daily Passengers (Min. 9)
Name of Driver
Employer of Driver
Daily Routes Traveled (Start – Finish – Towns)
Daily Miles Traveled
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.)
Schedule B
Odometer readings at the beginning and the end of period.
1.
Odometer reading at end of a period.
1.
2.
Odometer reading at beginning of a period.
2.
3.
Total mileage for a period.
3.
Schedule C
Computation of net refund.
1.
Total miles for period (Enter the total from Schedule B, Line 3.)
1.
2.
Total fuel gallons for period (Enter the total number gallons of fuel from Schedule A.)
2.
3.
Average miles per gallon (Divide Line 1 by Line 2.)
3.
4.
Total miles to and from work for this period
4.
5.
Refund gallons (Divide Line 4 by Line 3.)
5.
.00
6.
Tax refund claimed
(Multiply Line 5 by _____ per gallon. (See refund rate table on reverse side for appropriate rate.))
6. $
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 the 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
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