Form Au-736a - Motor Vehicle Fuels Tax (Motor Bus/taxicab) - Gasoline - Claim For Refund
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1STATE OF CONNECTICUT
DEPARTMENT OF REVENUE SERVICES
MOTOR FUEL SECTION
(MOTOR BUS/TAXICAB)
25 Sigourney Street, Hartford CT 06106-5032
INSTRUCTIONS
1. See reverse side for general instructions and information.
2. Mail original to the Department of Revenue Services at the above address.
3. REFUND CLAIMS MUST BE FILED BY MAY 31, 1999 for purchases made during
calendar year 1998.
FOR DEPARTMENT USE ONLY
Audit Number
CT Tax Registration Number / Social Security Number
Telephone Number
(
)
Claim Number
Name of Claimant (Please type or print)
Refund Gallons
Number and Street
Refund Tax
$
City or Town
State
ZIP+4
Reviewed By
Date
Location of Records (if different from above)
Type of Business
Approved By
Date
Prior Claim Filed for Period Ending
Period of Claim
/
/
From
To
Motor Fuel Purchased
Number of
Number of
Month
Purchased From
Month
Purchased From
Gasoline Gallons
Gasoline Gallons
Total Number of Gallons Purchased
1. Total operating miles
M
I
(Includes total miles traveled in and out of Connecticut by buses or taxicabs owned,
L
leased, or borrowed including charters)
E
S
C
2. Out-of-state mileage
T
O
R
A
3. Balance - miles operated on Connecticut roads (Subtract Line 2 from Line 1)
V
M
E
L
4. Percent of miles traveled on Connecticut roads
P
E
(Divide Line 3 by Line 1 - carry to .0001)
D
U
5. Total gallons of fuel used
T
M
(Include actual gallons of fuel used for all purposes)
O
T
6. Deduct fuel used other than in operation of motor buses or taxicabs
A
O
(Includes fuel used for cleaning, operation of non-highway equipment and motor vehicles
R
T
other than buses or taxicabs)
F
I
U
7. Net operating gallons used exclusively in motor buses or taxicabs
E
(Subtract Line 6 from Line 5)
L
O
8. Gallons used to operate motor buses or taxicabs on Connecticut roads
U
N
S
(Multiply Line 7 by Line 4)
E
D
9. Tax Refund Claimed (Multiply Line 8 by ________ per gallon.
(See instructions on reverse side for appropriate rate.)
$
I DECLARE UNDER THE PENALTIES OF FALSE STATEMENT THAT I HAVE EXAMINED THIS CLAIM AND TO THE BEST OF MY
KNOWLEDGE AND BELIEF IT IS TRUE, COMPLETE AND CORRECT.
Signature
Title
Date
Print Name
AU-736a (Rev. 7/98)
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