Form Au-725a - Motor Vehicle Fuels Tax Refund Claim - 2002
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1
2Department of Revenue Services
Form AU-725a
State of Connecticut
Excise/Public Services Taxes Subdivision
Motor Vehicle Fuels Tax Refund Claim
25 Sigourney Street
Gasoline — Farm Use Only
Hartford CT 06106-5032
Instructions
(Rev. 11/02)
1.
For instructions and additional information see reverse side.
2.
Mail original to the Department of Revenue Services (DRS) at the above address.
3.
Refund claims must be filed by May 31, 2003, for gasoline used during calendar year 2002.
Audit Number
CT Tax Registration Number / Social Security Number
Telephone Number
FOR DRS USE ONLY
(
)
Claim Number
Name of Claimant (Type or print)
Number and Street
Refund Gallons
City or Town
State
ZIP+4
Refund Tax
$
Location of Records (if different from above)
Type of Business
Reviewed By
Date
Prior Claim Filed for Period Ending
Period of Claim
Approved By
Date
/
/
From
To
No. of Storage Tanks
Meters
Total Capacity of
Acres Under Cultivation
Type of Farming
Storage Tanks
Yes
No
Non-taxable
Date
Purchased From
Number of Gasoline Gallons
Taxable Use
Use
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8
Beginning Inventory
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8
Ending Inventory
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8
Total Use
Computation of Claim
Multiply total non-taxable use by 25¢ (.25) per gallon $ ____________________
List and Identify All Commercially Registered Vehicles Owned or Operated (No refund for gasoline used in these vehicles) Attach additional sheets, if necessary.
Make
Year
Type
Motor Vehicle Reg. #
Make
Year
Type
Motor Vehicle Reg. #
Make
Year
Type
Motor Vehicle Reg. #
Make
Year
Type
Motor Vehicle Reg. #
List and Identify All Farm Registered Vehicles and Farm Implements for Which Refund is Claimed Attach additional sheets, if necessary.
Make and Type
Make and Type
Make and Type
Make and Type
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 that the penalty for willfully delivering a false return to DRS is a fine of not more than $5,000, or
imprisonment for not more than 5 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.
Signature
Title
Date
Print Name
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