Form A-3766 - Diesel Fuel Refund Claim
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1STATE OF NEW JERSEY
MAILING ADDRESS
State of New Jersey
DIVISION USE ONLY
DIVISION OF TAXATION
Division of Taxation
CLAIM #_________________________
MOTOR FUEL SECTION
DIESEL FUEL REFUND CLAIM
PO Box 243
CHECKED BY____________________
Trenton, New Jersey 08695-0243
GALLONS PURCHASED FROM
JAN - JUNE _____________________ (DUE BY JULY 31)
JULY - DEC _____________________ (DUE BY JAN 31)
_____________________________________________________________________________________________________________________________________________
NAME
SS #
_____________________________________________________________________________________________________________________________________________
STREET & NUMBER RFD
CITY OR TOWN
STATE
ZIP CODE
_____________________________________________________________________________________________________________________________________________
VEHICLE MODEL
WEIGHT
LICENSE PLATE
TOTAL GALLONS TO BE REFUNDED______________________________________________(attach supporting invoices)
A-3766
I hereby certify that the cost of the fuel and the New Jersey Motor Fuels Tax, thereon, for which refund is claimed herewith has been paid.
8-01, R-3
Signature _______________________________________
REQUIREMENTS
This Diesel Fuel Refund Claim Form is for passenger automobiles and motor vehicles of less than 5,000 lbs. gross weight.
ALL CLAIMS FOR REFUND MUST BE FILED NO LATER THAN SIX MONTHS AFTER DATE OF DELIVERY.
INVOICES MUST BE COMPLETELY PAID AND CONTAIN THE FOLLOWING:
• Name of claimant
• Date of Purchase
•Full Name and Address of supplier
• Number of Gallons Purchased
• Price
• NJ Motor Fuel Tax charged per gallon.
RECEIPTED COPIES OF INVOICES OR COPIES OF THE FRONT AND BACK OF CANCELED CHECKS THAT CAN BE RECONCILED TO THE
TOTAL AMOUNTS PURCHASED, PER YOUR ATTACHED CREDIT CARD STATEMENT AND INVOICES, WILL BE ACCEPTED AS EVIDENCE
OF PAYMENT.
Any person or the member of any firm or the officer or agent of any corporation who shall make false statement in any application required for the
reimbursement and repayment of any taxes, or who shall collect or cause to be repaid to him or to any other person any such reimbursement or refund without
being entitled to the same shall be guilty of a misdemeanor.
PRIVACY ACT NOTIFICATION
The Federal Privacy Act of 1974 requires all agencies requesting information to inform individuals from whom it seeks information why the request is being
made and how the information is being used.
Your social security number is used primarily to account for and give credit for tax payments. It is also used in the administration and enforcement of all
tax laws for which the Division of Taxation has statutory responsibility.
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