Form 706 Refund Claim - Maryland Motor Fuel Tax

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FORM

REFUND CLAIM FORM

MARYLAND

706

MOTOR FUEL

TAX

Class ______________________

Refund Status _______________

County Code ________________

Tran Status _________________

This claim is subject to audit and possible adjustment. This fuel may be

subject to sales and use tax. See instructions on page 2.

DO NOT WRITE IN SHADED AREAS

Account Number

Sequence Number

SSN / IRS Number

Type of Refund (Check one):

Name (1)

Farm

Name (2)

Construction

Address (1)

Boat (Commercial purposes only)

Address (2)

Aircraft

____________________________

(Specify reason for exempt qualification)

_______________________________________________________________

City, State, ZIP code

Other: _________________________________________________________

Telephone Number

Period of Claim

E-Mail Address

From ___________________________ To ___________________________

Period of Fuel Purchase

Column D

Column A

Column B

Column C

Tax Per

Gallon

Refund Amount

Enter Gallons

Enter Non- Refundable

Net Refundable

From ____________

Purchased Each Period

Gallons

(See

To ______________

Fuel Type

(Use rounded numbers)

LESS

(Use rounded numbers)

EQUALS

(Use rounded numbers)

TIMES

Chart)

EQUALS

GAS

DIESEL

AVIATION

.07

TOTALS

CERTIFICATION: Under penalties of perjury, I declare that I have examined this return, and I hereby certify that all statements herein made are true to the best of my knowledge

and belief, and that no part of the refund herein claimed has been heretofore paid. I further certify that the tax for which I am claiming a refund has been paid by me to the seller.

Signed: __________________________________________________________________________________ Date: ____________________________

COM/RAD-082

(Rev 12/15)