Form Rt-123 - Road Toll Refund Application printable pdf download

FOR OFFICIAL USE ONLY:

STATE OF NEW HAMPSHIRE

CLAIM NUMBER:

DEPARTMENT OF SAFETY

DIVISION OF ADMINISTRATION

CLASS NO.

NO. MOS.

APPROVED

DISALLOWED

ROAD TOLL BUREAU

GALS.

33 HAZEN DRIVE

CONCORD NH 03305

REASON NO.

DATE

TELEPHONE: (603) 271-2302

CLAIM NUMBER:

TDD Access: Relay NH 1-800-735-2964

CLASS NO.

NO. MOS.

APPROVED

DISALLOWED

ROAD TOLL REFUND APPLICATION

GALS.

OFF HIGHWAY RECREATIONAL VEHICLES, SNOWMOBILES, AND BOATS

REASON NO.

DATE

NAME OF APPLICANT:

STREET:

CITY/TOWN:

STATE-ZIPCODE:

TELEPHONE NUMBER:

CONTACT:

The above applicant has purchased and used for the purpose herein stated gasoline on which the Road Toll has

been paid. All equipment using gasoline must be listed on the reverse side and total gasoline consumed must

be accounted for.

ORIGINAL INVOICES of all gasoline purchases bearing name and address of supplier and NAME OF THE APPLICANT together with

evidence of payment must be attached. Evidence of payment-each invoice must be receipted by supplier as being paid or if payment

is made by check, date of payment together with check number must appear on invoice. No gasoline invoices shall be returned to an

applicant. Evidence of erasures or changes in either dates or amounts shown on invoices or evidence of payment shall result in the

invoices being disallowed. Invoices cannot be returned.

Per RSA 260:47, III, (i): Any person who shall be entitled to a refund of the road toll paid shall be reimbursed the amount of the road

toll paid subject to the following conditions: (i) Annually, no later than April 15

following the end of the calendar year.”

THE MINIMUM REFUND IS TEN DOLLARS ($10.00).

APPLICATIONS FOR LESS THAN TEN DOLLARS ($10.00) WILL NOT BE ACCEPTED

1. Total gallons, as per attached invoices

Gals.

2. Total gallons consumed on public ways

(col.5-line 17 & 19 (reverse side)

Gals.

3. Total gallons consumed off public ways

(col. 6-line 17 & 19 (reverse side)

Gals.

4. Amount of refund (Line 3 x .18)

I wish to donate $_________ of my refund to the Navigation Safety Fund (RSA 270-E:6-a)

NOTE

I wish to donate $_________ of my refund to the Lake Restoration & Preservation Fund (RSA 487:25)

5. Type of operation:

6. Where used: (city/town, state)

7. Columns 1 through 6 on the reverse side must be completed by applicant.

8. Stock Record-reverse side-must be completed if applicant has storage tanks or used drums

PRINT NAME:

DATE:

SIGNATURE:

TITLE:

“This application is signed under penalty of unsworn falsification pursuant to RSA 641:3.”

RT-123 (10/2008)

Form Rt-123 - Road Toll Refund Application

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