Form Rt115 - Road Toll Refund Application - Departament Of Safety Road Toll Bureau, State Of New Hampshire
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1
2OFFICE USE ONLY:
Claim No: ______________________
STATE OF NEW HAMPSHIRE
DEPARTMENT OF SAFETY
Class No.: ______________________
ROAD TOLL BUREAU
33 HAZEN DRIVE, CONCORD NH 03305
Total Toll Paid: $_________________
Telephone: (603) 271-2302
Amt. Of Refund: $________________
By: ______________
ROAD TOLL REFUND APPLICATION-RETAIL DEALER-IN ACCORDANCE WITH RSA 260:48
The statement on the reverse side must be completed by the applicant’s supplier. All gallonage figures should be checked for accuracy.
___________________________________________________________________________________________________________________________________
Name of Applicant*:_____________________________________________________________________________________________
Business Name*:__________________________________________
FEIN:______________________________________________
Retail Station Address:____________________________________________________________________________________________
City or Town:___________________________ New Hampshire:________________
Telephone No:__________________________
Zip Code
Mailing Address for Refund:_______________________________________________________________________________________
All Applications Must Be Accompanied By A Statement From A Licensed NH Distributor For Gross Purchases Of Motor Fuel Made
By The Retail Dealer During The Six Month Period.
*PER SAF-C 310:
•
(b) ”In order to be eligible to receive a retail dealer refund under RSA 260:48, a retail dealer shall be a separate legal entity
from any licensed distributor, as defined in RSA 259:21.”
•
(c) “For the purposes of this section, a trade name or a d/b/a shall not constitute a separate legal entity.”
APPLICANT’S CLAIM
Fuel Used For The Period Of ____________________through _______________ Year_______
GASOLINE
TAX PAID DIESEL
1. Gross Purchases, per statement:
Gallons
Gallons
2. Road Toll (rate per gallon)
.18
.18
3. Road Toll Paid:
$
$
4. Refund Rate (3/4 percent of Road Toll paid)
.0075
.0075
5. Amount of Refund:
$
$
Signature of Applicant_____________________________________________________________________
“
This application is signed under the penalty of unsworn falsification pursuant to RSA 641:3”
NOTE: SUCH APPLICATION SHALL BE FILED AND POSTMARKED WITHIN 90 DAYS AFTER EACH
SIX MONTH PERIOD ENDING JUNE 30 AND DECEMBER 31 RESPECTIVELY.
RT115 (
Revised 07/05)
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