Form Au-737 - Motor Vehicle Fuels Tax Refund Claim - 2009
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Department of Revenue Services
Form AU-737
State of Connecticut
Excise Taxes Unit
Received by DRS
Motor Vehicle Fuels Tax Refund Claim
25 Sigourney St Ste 2
Hartford CT 06106-5032
Airport Service Motor Bus
2009
(Rev. 09/09)
Period of claim in calendar year
____/____ through ____/____
You must check the appropriate fuel type box at right. Refund claims must be filed on or before May 31, 2010,
for fuel used during calendar year 2009. Complete this refund claim in blue or black ink only.
Connecticut Tax Registration Number
Federal Employer Identification Number (FEIN)
Print name of claimant
Telephone number
Social Security Number (SSN)
(
)
Number and street
Fuel type:
Diesel
Motor vehicle fuels
(gasoline-gasohol)
City or town
Claim type:
Airport service
(Motor bus)
State
ZIP code
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
Round to the nearest whole gallon.
Total:
Motor bus companies must attach a copy of their Certificate of Public Convenience and Necessity issued under
Chapter 244 of the Connecticut General Statutes with each claim filed.
Schedule B Computation of Net Refund
1.
Total miles for period
1.
2.
Total fuel gallons for period: Enter the total number of fuel gallons from Schedule A.
2.
3.
Average miles per gallon: Divide Line 1 by Line 2; carry to .0001.
3.
4.
Total Connecticut miles used for transportation of passengers to or from airport facilities
4.
5.
Refund gallons: Divide Line 4 by Line 3.
5.
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 the Department
of Revenue Services (DRS) is a fine of not more than $5,000, or imprisonment for not more than five 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
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