Form Rt-125g - Refund Application Municipal And County - Gasoline Only - Nh Department Of Safety Road Toll Bureau - 2005

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STATE OF NEW HAMPSHIRE
:
FOR OFFICIAL USE ONLY
DEPARTMENT OF SAFETY
CLAIM NUMBER:
DIVISION OF ADMINISTRATION
ROAD TOLL BUREAU
CLASS NO.
NO. MOS.
APPROVED
DISALLOWED
33 HAZEN DRIVE
GALS.
GALS.
CONCORD NH 03305
$
$
TELEPHONE: (603) 271-2302
BY
REASON NO.
TDD Access: Relay NH 1-800-735-2964
DATE
ROAD TOLL REFUND APPLICATION
MUNICIPAL AND COUNTY
GASOLINE ONLY
CITY, TOWN, SCHOOL DISTRICT, VILLAGE DISTRICT OR COUNTY
DEPARTMENT
(OFFICE ADDRESS) STREET
CITY/TOWN
STATE
ZIP CODE
TELEPHONE NUMBER
This is to certify that the above has purchased gasoline upon which the road toll has been paid and the gasoline
purchased was subsequently used in motor vehicles owned by the applicant, in accordance with RSA 260:47.
Period of ____________________ yr. __________ through ____________________ yr. __________
APPLICANT’S CLAIM
1. Total gallons, as per attached invoices
Gals.
2. Total gallons consumed:
Gals.
3. Amount of refund (Line 2 X $0.18)
$
______________
ORIGINAL INVOICES, BEARING THE NAME AND ADDRESS OF THE SUPPLIER AND THE NAME OF THE APPLICANT TOGETHER
WITH EVIDENCE OF PAYMENT MUST BE ATTACHED. INVOICES CANNOT BE RETURNED TO THE APPLICANT
.
Evidence of payment: Each invoice must be receipted by the supplier as being paid, or if payment is made by check, the date
of payment and check number must be supplied.
Per SAF-C 310.01 (f): “Motor fuel claimed on the refund application shall be the actual amount of motor fuel used by the
applicant. Application for a refund shall be submitted quarterly by the last day of the first quarter following the last quarter
included in the claim in accordance with RSA 260:47, III (a) which requires the same filing period for refunds as the filing
deadline for federal excise taxes on fuels.”
MINIMUM REFUND IS TEN DOLLARS ($10.00).
Evidence of erasures or changes in either the dates, amounts shown in the invoice or evidence of payment shall
result in the invoice being disallowed.
Signature
Title
"This application is signed under penalty of unsworn falsification pursuant to RSA 641:3."
RT-125G (Rev.07/05)

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