Form Au-737 - Motor Vehicle Fuels Tax Refund Claim - 2012

Department of Revenue Services

(For DRS Use Only)

Form AU-737

State of Connecticut



Excise Taxes Unit

2012

Motor Vehicle Fuels Tax Refund Claim

Period of claim in calendar year

25 Sigourney St Ste 2

Hartford CT 06106-5032

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__ __ through __ __

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Airport Service Motor Bus

(Rev. 06/12)

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Connecticut Tax Registration Number

Refund claims must be filed on or before May 31, 2013, for fuel used during calendar year 2012. You must

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



Print name of claimant

Telephone number

Type of business

Federal Employer Identification Number (FEIN)

(

)

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

Social Security Number (SSN)

Number and street

Check if change of address

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

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Fuel type:



Diesel

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City or town

State

ZIP code



Motor vehicle fuels (gasoline-gasohol)

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Claim type:



Airport service (motor bus)

Location of records if different from above

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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.

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.

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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 Connecticut miles used for transportation of passengers to or from airport facilities

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

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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 fine of not more than $5,000, 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