Form Rt125d - Road Toll Refund Application - Municipal And County - Tax Paid Diesel Only

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STATE OF NEW HAMPSHIRE
FOR OFFICIAL USE ONLY:
DEPARTMENT OF SAFETY
CLAIM NUMBER
DIVISION OF ADMINISTRATION
CLASS NO.
NO. MOS.
Road Toll Bureau
APPROVED
DISALLOWED
33 Hazen Drive
Concord, NH 03305
GALS.
GALS.
Tel. (603) 271-2302
TDD Access: Relay NH 1-800-735-2964
$
$
ROAD TOLL REFUND APPLICATION
BY
REASON NO.
MUNICIPAL AND COUNTY
TAX PAID DIESEL ONLY
DATE
CITY, TOWN, SCHOOL DISTRICT, VILLAGE DISTRICT OR COUNTY
DEPARTMENT
(OFFICE ADDRESS) STREET
CITY/TOWN
STATE
ZIP CODE
TELEPHONE NUMBER
This is to certify that the above has purchased diesel upon which the road toll has been paid and the diesel
purchased was subsequently used in motor vehicles owned by the applicant, in accordance with RSA
260:47.
Period of ____________________ yr. __________ through ____________________ yr. __________
APPLICANT’S CLAIM
MINIMUM REFUND IS TEN DOLLARS ($10.00)
1. Total gallons, as per attached invoices
Gals.
2. Total gallons consumed:
Gals.
$
3. Amount of refund (Line 2 X .18⊄)
______________
Invoices, bearing the name and address of the supplier and the NAME OF THE APPLICANT together with evidence of
payment must be attached. Invoices cannot be returned to the applicant.
Evidence of payment: Each invoice must be receipted by the supplier as being paid, or if payment is made by check, the
date of payment and check number must be supplied.
The diesel must actually be used and the refund applied for; Per RSA 260:47:
i. “Annually, no later than April 15 following the end of the calendar year, or
ii. If, at the close of the quarter of the calendar year at least $750 is payable in aggregate under these provisions
to such person with respect to fuel used during the calendar year, an application may be filed under this
subparagraph no later than the close of the subsequent quarter.”
Evidence of erasures or changes in either the dates, amounts shown in the invoice or evidence of payment shall result in the invoice being
.
disallowed
PRINT NAME:
DATE:
SIGNATURE:
TITLE:
“This application is signed under penalty of unsworn falsification pursuant to RSA 641:3.”
RT125D (Revised 10/08)

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