Form Au-737d - Motor Vehicle Fuels Tax Refund Claim - Connecticut Diesel-Livery Service
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1FORM AU-737d
STATE OF CONNECTICUT
DEPARTMENT OF REVENUE SERVICES
Motor Vehicle Fuels Tax Refund Claim
MOTOR FUEL SECTION
DIESEL-LIVERY SERVICE
25 SIGOURNEY STREET
HARTFORD CT 06106-5032
INSTRUCTIONS
(Rev. 11/00)
1. For additional instructions and information see reverse side.
2. Mail original to the Department of Revenue Services at the above address.
3. REFUND CLAIMS MUST BE FILED BY MAY 31, 2001, for diesel fuel used during calendar year 2000.
Audit Number
CT Tax Registration Number / Social Security Number
Telephone Number
(
)
FOR DEPARTMENT USE ONLY
Claim Number
Name of Claimant (Type or print)
Refund Gallons
Number and Street
Refund Tax
$
City or Town
State
ZIP+4
Reviewed By
Date
Type of Business
Location of Records (if different from above)
Approved By
Date
Prior Claim Filed for Period Ending
Period of Claim
/
/
From
To
Diesel Fuel Purchased
Number of
Number of
Date
Purchased From
Date
Purchased From
Diesel Gallons
Diesel Gallons
SCHEDULE
A
STATEMENT
OF
DIESEL FUEL
PURCHASES
Total Number of Diesel Gallons Purchased
1. Total miles for period
(Enter the total number of diesel
2. Total diesel gallons for period
gallons from Schedule A)
3. Average miles per gallon (Divide Line 1 by Line 2)
COMPUTATION
4. Total Connecticut miles used for transportation of passengers
5. Refund gallons (Divide Line 4 by Line 3)
(Multiply Line 5 by ________ per gallon.
$
6. Tax Refund Claimed
See rate table on reverse side for appropriate rate.)
I declare under the penalty of false statement that I have examined this claim, Form AU-737d, and, to the best of my knowledge and belief, it
is true, complete, and correct. (The penalty for false statement is imprisonment not to exceed one year or a fine not to exceed two
thousand dollars, or both.)
Signature
Title
Date
Print Name
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