Form Rt127d - Road Toll Refund Application - Private School Bus Owner

Form Rt127d - Road Toll Refund Application - Private School Bus Owner - Diesel Only Page 2

DIESEL USED FOR THE PERIOD OF ______________ YR_______ THROUGH _________________ YR ________

COLUMN 1

COLUMN 2

COLUMN 3

COLUMN 4

COLUMN 5

COLUMN 6

REG #/SERIAL #

GALLONS USED

GALLONS USED FOR

VEHICLE LISTING

MAKE

YEAR

(REQUIRED)

FOR SCHOOL

NON-SCHOOL DISTRICT

DISTRICT TRAVEL

TRAVEL

17 Totals

18 Transfer to Claim

Line 3 (on front)

19 Total Used Col. 5 + 6

Must equal Line 4 Stock Record

STOCK RECORD MUST BE COMPLETED IF APPLICANT HAS STORAGE TANKS OR PURCHASES IN DRUMS

STOCK RECORD

GALLONS

1. ACTUAL INVENTORY FIRST DAY OF PERIOD

2. TOTAL GALLONS (AS PER ATTACHED INVOICES)

3. TOTAL GALLONS TO BE ACCOUNTED FOR (LINE 1 AND 2)

4. TOTAL GALLONS USED (AS SHOWN ON LINE 19, COLS. 5 & 6)

5. TOTAL GALLONS SOLD

6. BOOK INVENTORY LAST DAY OF THE PERIOD (LINE 3 LESS LINES 4 AND 5)

7. ACTUAL INVENTORY LAST DAY OF PERIOD (STICK READING)

8. STOCK LOSS OR GAIN (DIFFERENCE LINES 6 & 7)

9. TOTAL GALLONS ACCOUNTED FOR (TOTAL LINE 4, 5, 7, & 8-MUST EQUAL LINE 3)

FOR OFFICIAL USE ONLY:

*** LIST MOTOR VEHICLES, REGISTRATION NUMBER REGARDLESS OF TYPE. APPLICANTS MAKING PURCHASES IN CANS (2, 5, 10

GALS.) OR BY DIRECT RECEIPT INTO FUEL TANKS ARE NOT REQUIRED TO COMPLETE STOCK RECORD BUT MUST COMPLETE COLS.

1 THROUGH 6.

RT127D (10/08)

Form Rt127d - Road Toll Refund Application - Private School Bus Owner - Diesel Only Page 2