Form Rt 122d - Road Toll Refund Application Toll Paid On Special Fuel Only printable pdf download

Form Rt 122d - Road Toll Refund Application Toll Paid On Special Fuel Only

STATE 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.

CONCORD NH 03305

REASON NO.

TELEPHONE: (603) 271-2302

DATE

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

IFTA LICENSE # ___________________

(IF APPLICABLE)

ROAD TOLL REFUND APPLICATION

FEIN: ______________________________

TOLL PAID ON SPECIAL FUEL 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 diesel on which the Road Toll has

been paid. All equipment using tax paid special fuel must be listed on the reverse side and total diesel

consumed must be accounted for.

ONLY PHOTOCOPIES of all 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. 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.

The special fuel must actually be used and the refund applied for; Per RSA 260:47: (i) “Annually, no later than April 15

following the end of the calendar year, or (ii) If, at the close of the quarter of the calendar year at least $750 is payable in

aggregate under these provisions to such person with respect to fuel used during the calendar year, an application may be

filed under this subparagraph no later than the close of the subsequent quarter.”

APPLICANTS’ CLAIM

MINIMUM REFUND IS TEN DOLLARS ($10.00)

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

PRINT NAME:

DATE:

SIGNATURE:

TITLE:

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

RT-122D (10/08)

Form Rt 122d - Road Toll Refund Application Toll Paid On Special Fuel Only

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