Form Rt126 - Road Toll Refund Application 2008 (Page 2 of 3) in pdf

Form Rt126 - Road Toll Refund Application 2008 Page 2

GASOLINE USED FOR THE PERIOD OF ______________ YR_______ THROUGH _________________ YR ________

COLUMN 1

COLUMN 2

COLUMN 3

COLUMN 4

COLUMN 5

COLUMN 6

GALLONS USED

**TYPE

***REG NO***

MAKE

YEAR

OFF

OF EQUIPMENT

(IF ANY)

HIGHWAY

17 Totals

18 Transfer to Claim

Line 2 (on front)

Line 3 (on front)

19 Total Used Col. 5 + 6

Must equal Line 4 Stock Record

STOCK RECORD MUST BE COMPLETED IF APPLICANT HAS STORAGE TANKS OR PURCHASES IN DRUMS

STOCK RECORD

GALLONS

1. ACTUAL INVENTORY FIRST DAY OF PERIOD

2. TOTAL GALLONS (AS PER ATTACHED INVOICES)

3. TOTAL GALLONS TO BE ACCOUNTED FOR (LINE 1 AND 2)

4. TOTAL GALLONS USED (AS SHOWN ON LINE 19, COLS. 5 & 6)

5. TOTAL GALLONS SOLD

6. BOOK INVENTORY LAST DAY OF THE PERIOD (LINE 3 LESS LINES 4 AND 5)

7. ACTUAL INVENTORY LAST DAY OF PERIOD (STICK READING)

8. STOCK LOSS OR GAIN (DIFFERENCE LINES 6 & 7)

9. TOTAL GALLONS ACCOUNTED FOR (TOTAL LINE 4, 5, 7, & 8-MUST EQUAL LINE 3)

FOR OFFICIAL USE ONLY:

**TRUCK, TRACTOR, CAR, STATIONARY MOTORS, ETC

*** LIST MOTOR VEHICLES, REGISTRATION NUMBER REGARDLESS OF TYPE.

APPLICANTS MAKING PURCHASES IN CANS (2, 5, 10 GALS.) OR BY DIRECT RECEIPT

INTO FUEL TANKS ARE NOT REQUIRED TO COMPLETE STOCK RECORD BUT MUST

COMPLETE COLS. 1 THROUGH 6.

RT-126 (Rev.10/08)

Form Rt126 - Road Toll Refund Application 2008 Page 2