Form 72a232 - Statement Of Claim For Accountable Loss Of Dyed Diesel - Kentucky Revenue Cabinet
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272A232 (7-00)
Submit in Triplicate
STATEMENT OF CLAIM FOR
Commonwealth of Kentucky
ACCOUNTABLE LOSS OF DYED DIESEL
REVENUE CABINET
Claim must be filed within 30 days from date of loss.
Specials Fuels Dealer’s
Name and Address of Dealer __________________________
License Number
FL–________________
(
)
–
Phone Number _____________________________________
Number of Special
Fuels Gallons Claimed
Contact Person _____________________________________
________________
NOTE: Please see reverse side for instructions before completing the items below.
1. Provide exact date of loss. ______________________________________________________________________________________
2. From what type of storage was the motor fuel lost?
Transport Truck
Bulk Plant
Service Station
Other ___________________________________________________________________________________________________
3. Where did the loss occur? _______________________________________________________________________________________
4. What method was used to determine the amount of loss? ______________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
5. What evidence is available to support loss? _________________________________________________________________________
6. Indicate the size of storage tank(s) in gallons. _______________________________________________________________________
7. If loss resulted from contamination, indicate number of gallons of motor fuel contaminated and returned to terminal storage. _______
_______________________ Terminal storage operator name and address of terminal. ______________________________________
____________________________________________________________________________________________________________
8. Indicate the type of loss (fire, flood, etc.), and briefly describe how the loss occurred. ______________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
I, the undersigned, a principal officer of the above-named licensee have examined this claim and it is, to the best of my knowledge and belief,
a true, correct and valid claim.
____________________________________________
______________________________
__________________ __________
Signature of Claimant
Title
Date
Print Name
Mail claim completed in triplicate with documentation to the Revenue Cabinet, Motor Fuels Tax Section, P.O. Box 1303, Frankfort, KY 40602-1303.
FOR CABINET USE ONLY
Special Fuels Gallons Approved ............................................................................
(Attach copy to 72A200. Claim this amount on line 8.)
Signature
Date
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