Form Gtr04-Motor Vehicle Fuel (Gasoline) Tax Refund Request July 2000 Page 2

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DESCRIPTION OF EQUIPMENT
REFUNDABLE
TAXABLE
MAKE, HORSEPOWER, LICENSE NUMBER, ETC.
PURPOSE FOR WHICH USED
GALLONAGE
GALLONAGE
Unaccounted for gallonage
///////////////////////////
Subtotal
Less duplicate invoice gallonage,
///////////////////////////
Filed on separate claim
Totals

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