Form Rt115 - Road Toll Refund Application - Departament Of Safety Road Toll Bureau, State Of New Hampshire Page 2

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(CLAIM FORM ON THE REVERSE SIDE MUST BE COMPLETED BY THE APPLICANT)
STATEMENT OF MOTOR FUEL SALES TO NEW HAMPSHIRE RETAIL DEALERS
This statement is prepared for and furnished to New Hampshire Retail Dealers to substantiate Road Toll Refund
claims as authorized under RSA 260:48
RSA 259:89 Retail Dealer.
"Retail dealer," for purposes of the provisions of this title relative to road tolls, shall mean any person or
persons other than a licensed distributor who engages primarily in the business of selling or distributing motor
fuel within this state at the retail level; provided further that retail dealer shall not include any person or persons
who receive motor fuel upon which the road toll has been paid by a licensed distributor for storage or subsequent
distribution at the wholesale level or solely for storage and consumption by such person or persons.
Name of Licensed Distributor ________________________________________________________________________
Telephone No.
Address: _________________________________________________________________________________________
Street
City/Town
State
Zip Code
Date___________
Year________
Name of Retail Dealer:___________________________________________________________________
Retail Station Address: __________________________________________________________________
Street
City/Town
State
Zip Code
THE UNDERSIGNED STATES THAT THE FOLLOWING MOTOR FUEL GALLONAGE WAS SOLD TO
THE ABOVE (RETAIL DEALER) FOR THE PERIOD INDICATED.
From ______________________________through _____________________year___________
SUMMARY OF GALLONS
GASOLINE
gallons
TAX PAID DIESEL
gallons
Please attach RT115 R in support of Gasoline and Tax Paid Diesel gallons
Signature_____________________________________ Title __________________________________________
("This application is signed under penalty of unsworn falsification pursuant to RSA 641:3.")
For_______________________________________________________________________________________
(Licensed Distributor)
RT115 (
Revised 07/05)

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