Form Gas-1200c - Motor Fuel Claim For Refund Qualified Power Takeoff Vehicles 2004 - North Carolina Department Of Revenue Page 3

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Page 3
Legal Name (First 10 Characters)
FEIN or SSN
GAS-1200C
Web
7-04
Part 4. Nonhighway Equipment
List nonhighway equipment reported on Part 1, Line 5 on which a refund is requested.
(Do not list licensed motor vehicles.)
Type of Machinery or Equipment
How many of each?
Type of Fuel Used
Engine H.P.
Part 5. Tank Wagon Vehicles
List licensed power takeoff tank wagons reported on Part 1, Line 6 on which a refund is requested.
(Do not list equipment or other qualified power takeoff vehicles that are not tank wagon vehicles.)
Make of Vehicle
Indicate Model of Vehicle
Type of Fuel Used
Gross Registered Weight
Part 6. Storage Tanks
List the type of fuel stored in bulk tanks and the capacity of each tank.
Tank Number
Fuel Type
Highway or Nonhighway Use
Gallon Capacity of Bulk Tank
Title:
Signature:
Date:
I certify that, to the best of my knowledge, this claim is accurate and complete.
Claims for Refund are due by April 15, 2005.
MAIL TO:
QUESTIONS:
North Carolina Department of Revenue
Contact the Motor Fuels Tax Division at:
Motor Fuels Tax Division
Telephone Number
(919) 733-3409
Post Office Box 25000
Toll Free Number
(877) 308-9092
Raleigh, North Carolina 27640-0950
Fax Number
(919) 733-8654

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