Form Au-736 - Motor Vehicle Fuels Tax Refund Claim

Form AU-736

Department of Revenue Services

Fuel Type

State of Connecticut

Motor Vehicle Fuels Tax Refund Claim

Motor Vehicle Fuels

Diesel

Excise Taxes Unit

Motor Bus, Taxicab & Livery

(Gasoline - Gasohol)

25 Sigourney Street

You must check the appropriate fuel type and claim type

Claim Type

Hartford CT 06106-5032

box on the right. Refund claims must be filed on or before

Motor

Taxicab

Livery

(Rev. 01/05)

May 31, 2005, for fuel used during calendar year 2004.

Bus

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

Less Use Tax

City or Town

SSN

Net Refund

State

ZIP+4

Due on or before

Reviewed By

Date

May 31, 2005

Approved By

Date

Type of Business

Location of Records (if different from above)

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.

Total operating miles

(Includes total miles traveled in and out of Connecticut by motor buses or taxicabs

owned, leased, or borrowed, including charters)

Enter the

Out-of-state mileage

Total - miles operated on Connecticut roads (Subtract Line 2 from Line 1)

Percent of miles traveled on Connecticut roads (Divide Line 3 by Line 1 - carry to .0001)

Total gallons of fuel used

(Include actual gallons of fuel used for all purposes)

Fuel used other than in operation of motor buses or taxicabs or livery

(Includes fuel used for cleaning, operation of non-highway equipment, and motor

vehicles other than motor buses or taxicabs or livery)

Net operating gallons used exclusively in motor buses, taxicabs, or livery (Subtract Line 6 from Line 5)

Gallons used to operate motor buses, taxicabs, or livery on Connecticut roads (Multiply Line 7 by Line 4)

.00

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 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