Form Rt 122g - Road Toll Refund Application Gasoline Only
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2STATE OF NEW HAMPSHIRE
FOR OFFICIAL USE ONLY:
DEPARTMENT OF SAFETY
CLAIM NUMBER:
DIVISION OF ADMINISTRATION
CLASS NO.
NO. MOS.
ROAD TOLL BUREAU
APPROVED
DISALLOWED
33 HAZEN DRIVE
GALS.
GALS.
$
$
CONCORD NH 03305
BY
REASON NO.
TELEPHONE: (603) 271-2302
DATE
TDD Access: Relay NH 1-800-735-2964
IFTA LICENSE # ___________________
(IF APPLICABLE)
ROAD TOLL REFUND APPLICATION
FEIN: ______________________________
GASOLINE ONLY
(IF APPLICABLE)
NAME OF APPLICANT:
STREET:
CITY/TOWN:
STATE-ZIPCODE:
TELEPHONE NUMBER:
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 SAF-C 310.01 (f): “Motor fuel claimed on the refund application shall be the actual amount of motor fuel used by the applicant.
Application for a refund shall be submitted quarterly by the last day of the first quarter following the last quarter included in the claim in
accordance with RSA 260:47, III (a) which requires the same filing period for refunds as the filing deadline for federal excise taxes on
fuels.” Minimum refund is ten dollars ($10.00). Applications for less than ten dollars ($10.00) will not be accepted. THE MINIMUM
REFUND IS TEN DOLLARS ($10.00). APPLICATIONS FOR LESS THAN TEN DOLLARS ($10.00) WILL NOT BE ACCEPTED
.
APPLICANTS’ CLAIM
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)
$
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
SIGNATURE:
TITLE:
“This application is signed under penalty of unsworn falsification pursuant to RSA 641:3.”
RT-122G (10/08)
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