Form Gas-1201c - Motor Fuel Claim For Refund Tax-Paid Motor Fuel Used Off-Highway 2004 - North Carolina Department Of Revenue
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1
2GAS-1201
Motor Fuel Claim for Refund
Web
Tax-paid Motor Fuel Used Off-Highway
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-1201 refund claim
Amended refund claim
Final refund claim for closed business
County
Street Address
Filed 2003 N.C. Income Tax Return
Filed 2003 Gas-1201 refund claim
Mailing Address
OFFICE USE
FEIN or SSN
(No dashes)
ONLY
City
State
Zip Code (First 5 digits)
Phone Number
Name of Contact Person
Fax Number
(
)
Refund for Calendar Year
(
)
2004
Business or Activity for which Refund is Claimed
IMPORTANT: You must complete all applicable Lines and Parts on this claim to receive a refund.
Part 1. Gallonage Accountability
Motor Fuel that
includes N.C. Road Tax
,
,
1.
Beginning inventory of tax-paid motor fuel on hand at first of year
1.
.0
,
,
2.
Total gallons of tax-paid motor fuel purchased during 2004
2.
.0
3.
Total gallons of tax-paid motor fuel to be accounted for
,
,
3.
.0
(Add Lines 1 and 2) (Must equal Line 7)
4.
Total gallons of tax-paid motor fuel used in off-highway equipment for which
,
,
4.
.0
refund is requested
,
,
5.
Total gallons of tax-paid motor fuel used in licensed vehicles for which no refund
5.
.0
is requested
,
,
6.
Ending inventory of tax-paid motor fuel on hand at end of year
6.
.0
,
,
7.
Total gallons of tax-paid motor fuel accounted for
7.
.0
(Add Lines 4, 5, and 6) (Must equal Line 3)
Part 2. Computation of Refund
8.
Refund due on tax-paid motor fuel used in off-highway equipment
,
8.
.
(Multiply Line 4 by $0.2445)
9.
Sales tax due on motor fuel used in off-highway equipment
,
a. General off-highway use
9a.
.
(Multiply Line 4 by $0.0696)
b. Manufacturers and Farmers (See instructions for certification)
,
9b.
.
(Multiply Line 4 by $0.0099)
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1
c. Commercial Fishermen, Railroads, and Ocean-Going Vessels
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1
9c.
(Exempt from sales tax; see instructions for certification)
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1
10. Total Refund Due
,
$
10.
.
(Line 8 minus Lines 9a and 9b)
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