Form Au-725b - Motor Vehucle Fuels Tax Refund Claim Form - Connecticut Department Of Revenue Services 2000

ADVERTISEMENT

FORM AU-725b
STATE OF CONNECTICUT
DEPARTMENT OF REVENUE SERVICES
Motor Vehicle Fuels Tax Refund Claim
MOTOR FUEL SECTION
25 SIGOURNEY STREET
DIESEL-FARM USE ONLY
HARTFORD CT 06106-5032
INSTRUCTIONS
(Rev. 11/00)
1. For additional instructions and information see reverse side.
2. Mail original to the Department of Revenue Services at the above address.
3. REFUND CLAIMS MUST BE FILED BY MAY 31, 2001, for diesel fuel used during calendar year 2000.
Audit Number
CT Tax Registration Number / Social Security Number
Telephone Number
FOR DEPARTMENT USE ONLY
(
)
Claim Number
Name of Claimant (Type or print)
Number and Street
Refund Gallons
City or Town
State
ZIP+4
Refund Tax
$
Location of Records (if different from above)
Type of Business
Reviewed By
Date
Prior Claim Filed for Period Ending
Period of Claim
Approved By
Date
/
/
From
To
No. of Storage Tanks
Meters
Total Capacity of
Acres Under Cultivation
Type of Farming
Storage Tanks
Yes
No
Non-taxable
Date
Purchased From
Number of Diesel Gallons
Taxable Use
Use
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8
Beginning Inventory
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8
Ending Inventory
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8
Total Use
Computation of Claim
Multiply total non-taxable use by .18 per gallon $ ____________________
List and Identify All Commercial Registered Vehicles Owned or Operated (No refund for diesel fuel used in these vehicles)
Make
Year
Type
Motor Vehicle Reg. # Make
Year
Type
Motor Vehicle Reg. #
Make
Year
Type
Motor Vehicle Reg. # Make
Year
Type
Motor Vehicle Reg. #
List and Identify All Farm Registered Vehicles and Farm Implements for Which Refund is Claimed
Make and Type
Make and Type
Make and Type
Make and Type
I declare under the penalty of false statement that I have examined this claim, Form AU-725b, and, to the best of my knowledge and belief, it
is true, complete, and correct. (The penalty for false statement is imprisonment not to exceed one year or a fine not to exceed two
thousand dollars, or both.)
Signature
Title
Date
Print Name

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Financial
Go