F.to.t. Application 7a/fuel Oil Tax Act Form

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F.O.T. APPLICATION 7A
FUEL OIL TAX ACT
REFUND OF FUEL OIL TAX COLLECTED VIA PREPAID SINGLE TRIP EMBLEM
Name___________________________________________________________________________________________
Address _________________________________________________________________________________________
Phone _________________________
Fax ________________________
Email _____________________________
Notes
1. Use a separate form for each fuel permit. Attach a copy of FUEL PERMIT and Yukon fuel receipts
2. Please submit Refunds by December 31st following the year of purchase.
3. Fuel receipts must show the date of purchase, fuel type, number of litres and fuel vendor name. Credit card slips without
details are not satisfactory proof of purchase.
Type of fuel:
DIESEL
GASOLINE
(Reefer fuel is not eligible)
STATEMENT OF TAX PAID
Date of purchase
Purchased from
Invoice no. (attach copies)
Litres purchased
Total purchases
CALCULATION OF TAX REFUND
Fuel tax refund will be the lesser of A or B
Single trip fuel permit no. ________________
A. Tax on ______________________ litres
Entry date ____________________________
Diesel oil x $0.072 /litre
Tax on ______________________ litres
=
$ ______________ A
Exit date _____________________________
Motorgrade gasoline x $0.062 litre
B. Cost of single trip Fuel Permit
= $ ______________ B
Refund $ ___________
LESSER OF A OR B
I, __________________________________________, ______________________________ as a duly authorized
print name
print title
officer of ____________________________________________________________________________________
print company name
hereby CERTIFY that I have not made a previous claim, nor received refund of tax, on the above mentioned fuel, nor
any part thereof and that all statements on this claim are true and correct to the best of my knowledge.
Date
Signature
Mail this return to:
Deputy Head, Department of Finance, Government of Yukon
Box 2703, Whitehorse, Yukon Y1A 2C6
Phone (867) 667-5345, Fax (867) 456-6709
The personal information requested on this form is collected under the authority of and used for the purpose of administering the Fuel Oil Tax Act.
Questions about the collection or use of this information can be directed to the Yukon Department of Finance, Box 2703, Whitehorse, Yukon, Y1A 2C6,
(867) 667-5343.
Publié aussi en français
YG(2348QE)F1 04/2013

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