Form Gas-1200c - Motor Fuel Claim For Refund Qualified Power Takeoff Vehicles 2004 - North Carolina Department Of Revenue
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2
3GAS-1200C
Motor Fuel Claim for Refund
Web
Qualified Power Takeoff Vehicles
7-04
MFD
North Carolina Department of Revenue
Legal Name
(First 30 Characters) (USE CAPITAL LETTERS FOR YOUR NAME AND ADDRESS)
Fill in applicable circles:
Address has changed since prior refund claim
Trade Name
First time filing Gas-1200C refund claim
Amended refund claim
Final refund claim for closed business
County
Street Address
Filed 2003 N.C. Income Tax Return
Filed 2003 Gas-1200C refund claim
Mailing Address
FEIN or SSN
OFFICE USE
(No dashes)
ONLY
City
State
Zip Code (First 5 digits)
Name of Contact Person
Phone Number
Fax Number
Refund for Calendar Year
(
)
(
)
2004
Business or Activity for which Refund is Claimed
IMPORTANT: Use a separate form Gas-1200C for each type of vehicle for which a refund is requested. You must complete all applicable Lines and Parts of this
claim to recieve a refund. Include motor fuel invoices with this claim that show the North Carolina road tax. Invoices for fuel that include sales tax, such as
fuel oil, dyed diesel fuel, or dyed kerosene, are not eligible for refund and should not be submitted.
Type of Vehicle for Which Refund is Requested - Fill in applicable circle
Bulk lime delivery to farms
Concrete mixing
Mulch blowing
Bulk feed delivery to poultry or
Solid waste compacting
livestock
Tank wagon motor fuel delivery
Bulk fertilizer delivery to farms
Part 1. Gallonage Accountability
Motor Fuel that
includes N.C. Road Tax
,
,
1.
Beginning inventory of N.C. tax-paid motor fuel on hand at first of year
1.
.0
,
,
.0
2.
Total gallons of N.C. tax-paid motor fuel purchased during 2004
2.
3.
Total gallons of N.C. tax-paid motor fuel to be accounted for
,
,
3.
.0
(Add Lines 1 and 2; must equal Line 8)
4.
Total gallons of N.C. tax-paid motor fuel used in licensed vehicles for which no
,
,
4.
.0
refund is requested
5.
Total gallons of N.C. tax-paid motor fuel used to operate nonhighway equipment
,
,
5.
.0
for which a refund is requested
(Enter amount here and on Part 3, Line 20)
6.
Total gallons of N.C. tax-paid motor fuel used to operate qualified power takeoff vehicles
,
a. Number of vehicles
6a.
,
,
b. Gallons of fuel used
6b.
(Enter amount here and on Part 3, Line 17)
,
,
.0
7.
Ending inventory of N.C. tax-paid motor fuel on hand at end of year
7.
8.
Total gallons of motor fuel accounted for
,
,
8.
.0
(Add Lines 4, 5, 6b, and 7; must equal Line 3)
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