Form Au-738 - Motor Vehicle Fuels Tax Refund Claim - Nutrition Program - 2008
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Form AU-738
Department of Revenue Services
Excise Taxes Unit
Received by DRS
Motor Vehicle Fuels Tax Refund Claim
25 Sigourney Street
Hartford CT 06106-5032
Nutrition Program
2008
Period of Claim in Calendar Year
(Rev. 07/08)
____/____ through ____/____
You must check the appropriate fuel type box at right. Refund claims must be filed on or before May 31, 2009,
Connecticut Tax Registration Number
for fuel used during calendar year 2008. Complete this refund claim in blue or black ink only.
Name of Claimant (Print)
FEIN
Telephone Number
SSN
(
)
Number and Street
Fuel Type:
Diesel
Motor Vehicle Fuels
(Gasoline-Gasohol)
City or Town
Claim Type:
Nutrition Program
State
ZIP+4
Type of Business
Location of Records (if different from above)
Schedule A
Statement of Motor Vehicle Fuel Purchases: Receipts must be attached. Attach additional sheet(s) as necessary to provide a complete response.
Date
Name of Supplier
Gallons of Fuel
Date
Name of Supplier
Gallons of Fuel
Total
Round to the nearest whole gallon.
You must attach a copy of your contract with your local area agency on aging as evidence of your eligibility to provide
Title III-C meals to senior citizens.
Schedule B
Computation of Net Refund
1.
Total miles for period
1.
2.
Total fuel gallons for period: Enter the total number of fuel gallons from Schedule A.
2.
3.
Average miles per gallon: Divide Line 1 by Line 2; carry to .0001.
3.
4.
Total miles in delivery vehicles used exclusively for the delivery of meals to senior citizens
4.
5.
Refund gallons: Divide Line 4 by Line 3.
5.
6.
Tax refund claimed: Multiply Line 5 by _______ per gallon. See Refund Rates on reverse.
6.
$
.00
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
Email Address
(
)
Print Preparer Name
Preparer’s SSN or PTIN
Email Address
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