Form Au-736a - Motor Vehicle Fuels Tax Refund Claim Gasoline -Motor Bus/taxicab 2002
ADVERTISEMENT
1Department of Revenue Services
Form AU-736a
State of Connecticut
Excise/Public Services Taxes Subdivision
Motor Vehicle Fuels Tax Refund Claim
25 Sigourney Street
Gasoline — Motor Bus/Taxicab
Hartford CT 06106-5032
Instructions
(Rev. 11/02)
1.
For instructions and additional information see reverse side.
2.
Mail original to the Department of Revenue Services (DRS) at the above address.
3.
Refund claims must be filed by May 31, 2003, for gasoline used during calendar year 2002.
FOR DRS USE ONLY
CT Tax Registration Number / Social Security Number
Telephone Number
Audit Number
(
)
Name of Claimant (Type or print)
Claim Number
Number and Street
Refund Gallons
City or Town
State
ZIP+4
Refund Tax
$
Reviewed By
Date
Type of Business
Location of Records (if different from above)
Approved By
Date
Prior Claim Filed for Period Ending
Period of Claim
From
To
/
/
Gasoline Purchased
Number of
Number of
Date
Purchased From
Date
Purchased From
Gasoline Gallons
Gasoline Gallons
Total Number of Gasoline Gallons Purchased
M
1. Total operating miles
i
(Includes total miles traveled in and out of Connecticut by motor buses or taxicabs owned,
l
e
leased, or borrowed, including charters)
s
C
T
2. Out-of-state mileage
o
r
a
v
3. Total - miles operated on Connecticut roads (Subtract Line 2 from Line 1)
m
e
l
4. Percent of miles traveled on Connecticut roads
p
e
(Divide Line 3 by Line 1 - carry to .0001)
d
u
5. Total gallons of gasoline used
t
(Include actual gallons of gasoline used for all purposes)
6. Gasoline used other than in operation of motor buses or taxicabs
a
G
a
(Includes gasoline used for cleaning, operation of non-highway equipment, and
s
t
motor vehicles other than motor buses or taxicabs)
o
l
i
i
7. Net operating gallons used exclusively in motor buses or taxicabs
n
(Subtract Line 6 from Line 5)
o
e
8. Gallons used to operate motor buses or taxicabs on Connecticut roads
U
n
s
(Multiply Line 7 by Line 4)
e
d
9. Tax Refund Claimed
(Multiply Line 8 by _____ per gallon. See refund rate table on reverse side for appropriate rate.)
$
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 that the penalty for willfully delivering a false return to DRS is a fine of not more than $5,000, or
imprisonment for not more than 5 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.
Signature
Title
Date
Print Name
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial