Form Au-736 - Motor Vehicle Fuels Tax Refund Claim - 2016

Department of Revenue Services

Form AU-736

State of Connecticut

(For DRS Use Only)

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Excise Taxes Unit

Motor Vehicle Fuels Tax Refund Claim

450 Columbus Blvd Ste 1

Period of claim in calendar year

2016

Hartford CT 06103-1837

Motor Bus, Taxicab, and Livery

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(Rev. 02/17)

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Refund claims must be fi led on or before May 31, 2017, for fuel used during calendar year 2016. You must

Connecticut Tax Registration Number

check the appropriate fuel type box at right. Complete this refund claim in blue or black ink only.

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Print name of claimant

Telephone number

Type of business

Federal Employer Identifi cation Number (FEIN)

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(

)



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Social Security Number (SSN)

Number and street

Check if change of address

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

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Fuel type:

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Diesel

City or town

State

ZIP code

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Motor vehicle fuels (gasoline-gasohol)

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Claim type:

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Motor bus

Location of records if different from above

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Taxicab

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Livery

Schedule A -

Statement of motor vehicle fuel purchases by month: Receipts must be attached. Attach additional sheet(s) as necessary to provide a complete response.

Month

Name of Supplier

Gallons of Fuel

Month

Name of Supplier

Gallons of Fuel

Total:

Round to the nearest whole number.

Motor bus companies must attach a copy of their Certifi cate of Public Convenience and Necessity issued under Chapter 244 of the

Connecticut General Statutes with each claim fi led.

Taxicab operators must attach a copy of their Certifi cate of Public Convenience and Necessity issued under Chapter 244a of the

Connecticut General Statutes with each claim fi led.

Livery service operators must attach a copy of their permit issued under Chapter 244b of the Connecticut General Statutes with

each claim fi led. Livery service vehicles are refunded at half the motor vehicle fuels tax rate.

Schedule B -

Computation of net refund

1.

Total operating miles: Includes total miles traveled in and out of Connecticut by motor buses,

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taxicabs, or livery vehicles owned, leased, or borrowed, including charters.

1.

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2.

Out-of-state mileage: Enter the out-of-state mileage.

2.

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3.

Total miles operated on Connecticut roads: Subtract Line 2 from Line 1.

3.

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4.

Percent of miles traveled on Connecticut roads: Divide Line 3 by Line 1; carry to .0001.

4.

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5.

Total gallons of fuel used: Include actual gallons of fuel used for all purposes.

5.

6.

Fuel used other than in operation of motor buses, taxicabs, or livery: Includes fuel used for cleaning,

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operation of non-highway equipment, and motor vehicles other than motor buses, taxicabs, or livery.

6.

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7.

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

7.

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8.

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

8.

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9.

Tax refund claimed: Multiply Line 8 by ________ per gallon. See Refund Rates on reverse.

9.

$

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 DRS is a fi ne of not more than $5,000, imprisonment for not more than fi ve 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’s name

Telephone number

(

)

Taxpayer’s email address

Print preparer’s name

Preparer’s SSN or PTIN

Preparer’s email address