Form Gr-3 - Preliminary Refund Questionnaire

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GR-3 (Rev. 07-04)
(For Office Use Only)
PRELIMINARY REFUND QUESTIONNAIRE
Title 54, Taxation, Subtitle 6,
STATE OF NEW JERSEY
Classification
Chapter 39,
DEPARTMENT OF THE TREASURY
Code No.
Revised Statutes as Amended
DIVISION OF TAXATION
Checked
MOTOR FUELS TAX
THIS QUESTIONNAIRE MUST BE COMPLETELY FILLED OUT AND FILED WITH THE DIVISION OF TAXATION, MISCELLANEOUS TAX BRANCH,
PO BOX 269, TRENTON NJ 08695-0269, BEFORE ANY CLAIM FOR REFUND OF THE NEW JERSEY MOTOR FUELS TAX WILL BE CONSIDERED.
Read instructions BEFORE Filling Out the Questionnaire
Date _____________________________
1.
Name of Claimant ________________________________________________________________________________________________
(Print Name to which refund claims will be made)
2.
Address ________________________________________________________________________________________________________
(Print Street and Number)
3.
Town or City ___________________________ County ______________________________ State ___________________ Zip ________
(Print)
(Print)
(Print)
If other than individual, answer Questions 4 and 5.
4.
State whether partnership or corporation ______________________________________________________________________________
5.
Give name, address and title of the person whom you authorize to sign refund claims ___________________________________________
___________________________________________________________________________________________________
6.
Refer to Instructions and check all of the uses for which you will claim a refund of the Motor Fuel Tax.
7.
Give below, your estimate of the APPROXIMATE number of gallons of motor fuel you will use each month of the year for refundable and
nonrefundable purposes. The figures placed in the columns “Gallons” should give this Division as nearly as possible the number of gallons of
gasoline you expect to use during each month for which you can legally claim a refund. In those months of the year that you will not use
gasoline insert the word “NONE”. It is very important that this estimate be given. Your questionnaire will not be accepted without it.
Gallons
Gallons
Gallons
Gallons
Month
Month
Month
Month
(Refund)
(No Refund)
(Refund)
(No Refund)
(Refund)
(No Refund)
(Refund)
(No Refund)
Apr
July
Oct
Jan
May
Aug
Nov
Feb
June
Sept
Dec
Mar
8.
Give (in as few words as possible) a statement of operation in which you will use motor fuel which will be subject to refund of the Motor Fuel tax.
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Will you keep a record of purchases and uses of Motor Fuel as required by this Division? ______________________________________
(Yes or No)
9.
List all your equipment in which you will use motor fuel (including automobiles, trucks and tractors using kerosene, diesel oil or any type of
fuel) ___________________________________________________________________________________________________________
Equipment
Make
Gas or Diesel
Licensed? Yes or No
Year
Model
If more space is required use and attach an additional sheet.
9a. Do you supply gasoline to anyone? _________________
Fuel Storage Capacity ______________________________________
What is the number of same? ______________________
Do you have a Motor Fuel Retail Dealers’ License? ____________
10. The undersigned herby declares that the statements contained herein are true and that signature has been affixed with full knowledge that
any person or member of any firm or the officer or agent of any corporation who shall make any false statement in the application required
for reimbursement and repayment of any taxes, or who shall collect or cause to be repaid to him or to any other person any such
reimbursement or refund without being entitled to the same shall be guilty of a crime in accordance with N.J.S.A. 54:39-67.
(Signature)
(Title)

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