Retail Dealer'S Gasoline Shrinkage Refund Application Form

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RDGS
Maine Revenue Services
Retail Dealer’s Gasoline Shrinkage
00
Refund Application
*0733000*
Registration No.
Period Begin
Period End
Due Date
1. Entity Information
Use this area only to report changes in your business
2. OUT OF BUSINESS?
Check here
, return permit to Bureau and
complete information at right. Date closed:
3. OWNERSHIP CHANGE?
If you have changed ownership, indicate the date
when this occured here
and check the type of change below.
Partner added or dropped
Incorporated
Other (explain on reverse)
Sold to
4. NAME CHANGE?
Attach explanation to this return.
ADDRESS CHANGE?: If your address above is incorrect, please make the
Do Not Use Red Ink!
appropriate changes to the preprinted address and check here
Please read instructions on reverse side.
Also complete questions 1 & 2 on reverse.
,
,
Total purchases in gallons
1.
,
,
.
Total Tax Paid
Line 1 x .276
2.
,
,
.
Refund Claim
Line 2 x .005
3.
This claim is signed under the penalties of perjury.
Date
Signature/Title
Print Name
Phone #
Mail To:
/
Maine Revenue Service
P.O. Box 1064
Augusta, ME 04332-1064
Supplier’s Statement
The undersigned states that the following gallonage of gasoline was sold to the above retail dealer for the above period, that payment has been received for
such gasoline, and that he is authorized to make this statement.
Regular gasoline
gallons
Premium gasoline
gallons
Total Gallons
Date
Name of Supplier
Authorized Signature
RDGS - Revised 10/07
For assistance in completing this form, call (207) 624-9609

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