Form Rt126 - Road Toll Refund Application 2008 printable pdf download

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.

Tel. (603) 271-2302

TDD Access: Relay NH 1-800-735-2964

ROAD TOLL REFUND APPLICATION

REASON NO.

FARM USE ONLY

DATE

(NAME OF APPLICANT)

(STREET)

(CITY/TOWN)

(STATE)

(ZIP CODE)

(TELEPHONE NUMBER)

The above applicant has purchased and used for Farming purposes herein stated Motor Fuel on which Road Toll has been

paid. All equipment using Motor Fuel must be listed on the reverse side, and total Motor Fuel consumed must be accounted for.

INVOICES of all GASOLINE PURCHASES, PHOTOCOPIES OF INVOICES for all UNDYED DIESEL PURCHASES, bearing name & address of

supplier and the NAME OF THE APPLICANT together with evidence of payment must be attached. Evidence of Payment: Each invoice must be

receipted by supplier as being paid, or if payment is made by check, date of payment together with check number must appear on the invoice. No

gasoline invoice shall be returned to an applicant. If there is any evidence of erasures, or changes in either dates or amounts shown on invoices or of

payment of road toll, the application will be disallowed in its portion

The gasoline and undyed 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.”

APPLICANT’S CLAIM

Fuel Used for the Period of ________________ thru _______________ yr. _________

GASOLINE

UN-DYED DIESEL

1. Total gallons, as per attached invoices

Gals.

2. Total gallons consumed ON public ways

(col. 5 – line 17 – reverse side)

Gals.

3. Total gallons consumed OFF public ways

(col. 6 – line 17 – reverse side)