Form A-3711-Mf - Refund Claim - Motor Fuel Tax 2000
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1
2State of New Jersey
(DO NOT USE)
A-3711-MF (10-00, R9)
DEPARTMENT OF THE TREASURY
Refund No __________________________
DIVISION OF TAXATION
Claim Required by
Title 54, Taxation, Subtitle 6,
MOTOR FUEL TAX
Chapter 39, Revised
Claim Checked by ___________________
REFUND CLAIM
Statutes as Amended
This claim must be postmarked no later than the last business day of the sixth month following the month during which the fuels were
R
R
E
purchased. Send this claim to the DIVISION OF TAXATION, Motor Fuels Tax Section, PO Box 243, Trenton, NJ 08695. This claim
E
A
shall cover all the purchases in that calendar month which you set forth in the space directly below.
A
D
D
DO NOT INCLUDE PURCHASES OF MORE THAN ONE CALENDAR MONTH.
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USE TYPEWRITER OR PRINT WITH INK
FUELS PURCHASED DURING MONTH OF ___________________ ______ CLAIMANT’S 7 DIGIT CODE NUMBER
Not Transferable
_______________________________________________________________________________________________________________________________
Name
_______________________________________________________________________________________________________________________________
Street & Number or R.F.D.
City or Town
State
Zip Code
hereby certifies that the cost of the fuel and the N.J. Motor Fuels Tax, thereon, for which refund is claimed herewith has been paid.
2
GALLONS
STATEMENT OF PURCHASES AND USES
(Omit Tenths)
(Show all N.J. purchases of Motor Fuel regardless of use and attach invoices in support thereof)
(a) TOTAL number of N.J. gallons purchased this month . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(b) Number of gallons upon which NO REFUND is claimed. (Show gallons used on highways, and other non-refundable
gallons). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(c) Number of gallons upon which REFUND of the NEW JERSEY motor fuel tax is claimed . . . . . . . . . . . . . . . . . . . . . . .
(Attach fully receipted invoices in support thereof.)
(d) The Motor Fuel on which Refund is claimed was used for the following purpose(s):
GALLONS
PURPOSE
(Omit Tenths)
DO NOT USE
The following list includes all refundable uses of Motor Fuel.
Diesel
Gasoline
Insert in the “Gallons” column, opposite the proper use, the number of gallons, used in each.
1. Diesel fuel as used by passenger automobiles and motor vehicles of less than 5,000 pounds gross
weight. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2. Operating autobusses over the highways of this State under the provisions of 48:16-25 of the Title
Public Utilities and pursuant to R.S. 48:4-1 and 48:4-3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3. Operating aircraft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4. Operating agricultural tractors on private property and/or farm machinery . . . . . . . . . . . . . . . . . . . .
5. Operating highway motor vehicles, such as trucks and automobiles, exclusively on private property
6. Operating stationary machinery, or vehicles or implements not designed for transporting persons or
property on public highways, such as pumps, mixers, cranes, shovels, bulldozers, graders, carriers, fork
lifts and like industrial or construction vehicles, implements or machinery. Also block testing. . . . .
7. Cleaning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8. Operating fire engines and fire fighting apparatus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9. Operating ambulances. Operating emergency vehicles used exclusively by volunteer first-aid or rescue
squads. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10. Operating vehicles running only on rails or tracks. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11. Heating and lighting. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12. Operating motor boats or motor vessels used exclusively for Sea Scout Training by a duly chartered
unit of the Boy Scouts of America. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
13. Exported from the State of New Jersey to another State or country. . . . . . . . . . . . . . . . . . . . . . . . . .
14. Operating watercraft used (a) for oystering or clamming, (b) commercial fishing or (c) the carrying of
fishing parties for hire, or (d) for sightseeing or excursion parties. . . . . . . . . . . . . . . . . . . . . . . . . .
Check which use . . . . (a)
(b)
(c)
(d)
15. Rural free delivery carrier in the dispatch of official business.
1st Test:____________________ gals.______________ Date made:________________________
2nd Test:____________________ gals.______________ Date made:________________________
Average of Tests _____________ gals. X ____________ Trips made this month. ______________
NOTE: (This figure must agree with Line (c) above) . . . . . . . . . . . . . . . . . . . . .
TOTAL
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