Form Ifta-116 - Fuel Use Tax Refund For B20 Fuel - State Of New York
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1
2IFTA-116
New York State Department of Taxation and Finance
Fuel Use Tax Refund for B20 Fuel
(4/11)
International Fuel Tax Agreement (IFTA)
Employer identification number (EIN)
Suffix (if any) Social security number (SSN; if no EIN )
Suffix (if any)
Name of carrier
Street address
City
State
ZIP code
IFTA base jurisdiction
Attach a copy of the applicable IFTA tax return and a copy of the invoices for purchases of B20 in the other jurisdiction.
Computation of refund
(see instructions; attach additional sheets if necessary)
1 Enter the abbreviation for the jurisdiction where
B20 was purchased
(attach a copy of the
...................................
1.
receipts and tax return(s))
2 Enter the quarter ending date
.......
2.
(mm/dd/yyyy)
3 Gallons of B20 purchased in jurisdiction on
3.
line 1
.............................
(per attached invoices)
4 Taxable Gallons of diesel consumed in the
jurisdiction on line 1
4.
(from your IFTA tax return)
5 Gallons available for consumption in other
5.
jurisdictions
.............
(subtract line 4 from line 3)
6 Taxable Gallons of diesel consumed in
New York
.................
6.
(from your IFTA tax return)
7 Total Taxable Gallons of diesel consumed in
7.
all IFTA jurisdictions
(from your IFTA tax return)
8 Taxable Gallons of diesel consumed in
jurisdiction on line 1
8.
(from your IFTA tax return)
9 Total Taxable Gallons of diesel consumed in all
IFTA jurisdictions except jurisdiction on line 1
9.
.................................
(subtract line 8 from line 7)
10 New York ratio of taxable gallons
(divide line 6
................ 10.
by line 9; round to four decimal places)
11 Gallons allocated to New York
(multiply line 10
........................ 11.
by line 5; round to nearest gallon)
12 Net Taxable Gallons for New York
(from your
................................................. 12.
IFTA tax return)
13 Enter the lesser of line 11 or line 12
(if less
.................................................. 13.
than 0, enter 0)
14 New York diesel rate for the quarterly period ... 14.
15 B20 rate difference
................... 15.
(see instructions)
16 Refund amount
........... 16.
(multiply line 13 by line 15)
17 Total refund
........................ 17.
(add line 16 columns)
Certification: I, the claimant, or an officer or authorized representative of the claimant, do hereby make application for refund of
the fuel use tax. I certify that this refund claim and any attachments are to the best of my knowledge and belief, true, correct, and
complete, and that no refund of any part of this claim has been claimed from another jurisdiction. I make these statements with the
knowledge that knowingly making a false or fraudulent statement on this document is a misdemeanor under section 210.45 of the
Penal Law, punishable by imprisonment for up to a year and a fine of up to $5,000.
Signature of authorized person
Title
County
Date
Preparer’s signature
Date
Preparer’s NYTPRIN
Preparer’s SSN or PTIN
Mark
Paid
an X if
preparer
self-employed
use
Preparer’s firm name
Firm’s EIN
E-mail
(or yours, if self-employed)
only
Address
Telephone number
(
)
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