Form Ft-500 - Application For Refund Of Sales Tax Paid On Petroleum Products - Nys Department Of Taxation And Finance Page 3

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FT-500 (9/11) Page 3 of 3
Schedule of motor fuel and diesel motor fuel purchases
A
B
C
D
E
F
G
H
Date of
Seller’s name
Delivery location
Invoice
Type of
Number of
Total
Sales tax
purchase
number
product*
gallons
sales tax
refund claimed
(city and county)
(see Pub 902)
(on invoice)
(dollars and cents)
Total amount of refund claimed
(enter amount on page 1, line 7)

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