Form Au-737 - Motor Vehicle Fuels Tax Refund Claim - Airport Service (Motor Bus) - 2004
ADVERTISEMENT
1
2Form AU-737
Department of Revenue Services
Fuel Type
State of Connecticut
Motor Vehicle Fuels Tax Refund Claim
Motor Vehicle Fuels
Diesel
Excise Taxes Unit
(Gasoline - Gasohol)
Airport Service (Motor Bus)
25 Sigourney Street
Claim Type
You must check the appropriate fuel type box
Hartford CT 06106-5032
on the right. Refund claims must be filed on or before
Airport Service (Motor Bus)
(Rev. 01/05)
May 31, 2005, for fuel used during calendar year 2004.
FOR DRS USE ONLY
Audit Number
Name of Claimant (Type or print)
Period of Claim in Calendar Year
2004
____/____
through
____/____
Claim Number
Voucher Number
Telephone Number
CT Tax Registration Number
(
)
Refund Gallons
Number and Street
FEIN
Refund
$
City or Town
SSN
Net Refund
$
State
ZIP+4
Due on or before
Reviewed By
Date
May 31, 2005
Type of Business
Location of Records (if different from above)
Approved By
Date
Schedule A
Statement of Motor Vehicle Fuel Purchases. Receipts must be attached.
Date
Name of Supplier
Gallons of Fuel
Date
Name of Supplier
Gallons of Fuel
Total
(Round to the nearest whole gallon.)
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)
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.
.00
6.
Tax refund claimed
(Multiply Line 5 by _____ per gallon. (See refund rate table on reverse side for appropriate rate)
6. $
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 to 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 Name
Telephone Number
Date
Print Preparer Name
Preparer’s Address
Preparer’s SSN or PTIN
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial