Form Ifta-115 - Alternative Tax Rate Claim For Fuel Use Tax Refund
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1IFTA-115
Alternative Tax Rate
(4/11)
Claim for Fuel Use Tax Refund
(for Fuel Purchased on and After January 1, 1996)
Tax Law - Article 21-A
Type or print in ink.
Employer identification number (and suffix, if any)
Social security number (if no EIN)
Mail to:
NYS TAX DEPARTMENT
Name of carrier
TDAB/IFTA
W A HARRIMAN CAMPUS
ALBANY NY 12227
Street address
City
State
ZIP code IFTA base jurisdiction
Computation of Refund
A
B
C
D
E
F
Quarterly
Fuel
Net New York taxable gallons
New York tax rate
Alternative New York
Net refund claimed
period
type
(from IFTA report)
(from IFTA report)
tax rate
C × (D - E)
(month/year)
Total refund claimed
(add column F amounts) .............................................................................................
Certification. I certify that this refund claim and any attachments are to the best of my knowledge and belief true, correct and complete.
Signature of elected officer or authorized person
Official title
Telephone number
Date
(
)
Preparer’s signature
Date
Preparer’s NYTPRIN
Preparer’s SSN or PTIN
Mark
Paid
an X if
preparer
self-employed
use
Preparer’s firm name
Firm’s EIN
E-mail
(or yours, if self-employed)
only
Address
Telephone number
(
)
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Parent category: Financial