Form Au-738 - Motor Vehicle Fuels Tax Refund Claim - 2011

Department of Revenue Services

Received by Department of Revenue Services (DRS)

Form AU-738

State of Connecticut

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Excise Taxes Unit

Period of claim in calendar year

2011

Motor Vehicle Fuels Tax Refund Claim

25 Sigourney St Ste 2

Hartford CT 06106-5032

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Nutrition Program

(Rev. 06/11)

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Connecticut Tax Registration Number

Refund claims must be fi led on or before May 31, 2012, for fuel used during calendar year 2011. You must

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check the appropriate fuel type box at right. Complete this refund claim in blue or black ink only.

Federal Employer Identifi cation Number (FEIN)

Print name of claimant

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Telephone number

Social Security Number (SSN)

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(

)

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Number and street

Fuel type:

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Diesel

City or town

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

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Motor vehicle fuels (gasoline-gasohol)

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Claim type:

State

ZIP code

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Nutrition program

Type of business

Location of records if different from above

Schedule A - Statement of motor vehicle fuel purchases: Receipts must be attached. Attach additional sheet(s) as necessary to provide a

complete response.

Date

Name of Supplier

Gallons of Fuel

Date

Name of Supplier

Gallons of Fuel

Total:

Round to the nearest whole gallon.

You must attach a copy of your contract with your local area agency on aging as evidence of your eligibility to provide Title III-C meals

to senior citizens.

Schedule B - Computation of net refund

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1.

Total miles for period

1.

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2.

Total fuel gallons for period: Enter the total number of fuel gallons from Schedule A.

2.

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3.

Average miles per gallon: Divide Line 1 by Line 2; carry to .0001.

3.

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4.

Total miles in delivery vehicles used exclusively for the delivery of meals to senior citizens

4.

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5.

Refund gallons: Divide Line 4 by Line 3.

5.

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6.

Tax refund claimed: Multiply Line 5 by _______ per gallon. See Refund Rates on reverse.

6.

$

00

Declaration: I declare under penalty of law that I have examined this return (including any accompanying schedules and statements) and, to the best of my knowledge and belief, it is

true, complete, and correct. I understand the penalty for willfully delivering a false return or document to DRS is a fi ne of not more than $5,000, imprisonment for not more than fi ve years,

or both. The declaration of a paid preparer other than the taxpayer is based on all information of which the preparer has any knowledge.

Taxpayer signature

Title

Date

Print taxpayer’s name

Telephone number

Email address

(

)

Print preparer’s name

Preparer’s SSN or PTIN

Email address