Form Tp-164.14 - Application For Refund Of New York State Motor Fuel Tax By An Omnibus Carrier

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TP-164.14 (11/06)
New York State Department of Taxation and Finance
Application for Refund of New York State
Motor Fuel Tax by an Omnibus Carrier
Do not write in this space
Audited and approved
for payment
Tax Law — Article 12-A, Section 289-c
Office of the State Comptroller
This form is to be used by an omnibus carrier (definition on back).
Audited by
Date approved
Check number
Beginning
Ending
Filing
Department of Taxation and Finance
Do not use this form for diesel tax refund.
period
Line 1
gal. $
Name of claimant
Business telephone number
Line 2
gal. $
(
)
Street address
City
State
ZIP code
Total refunds $
Audited by
Date
Records are kept at
Approved by
Date
Approved by
Date
Federal employer identification number or social security number
Total number of
Received
buses operated:
Gasoline
Diesel
Department of Taxation and Finance
Mark an X in the appropriate box when answering Yes or No questions.
Do you have a Department of Transportation Certificate of Convenience
and Necessity? .................................................................................................... Yes
No
Do you have an Interstate Commerce Commission Certificate of Convenience
and Necessity? .................................................................................................... Yes
No
Do you operate pursuant to a contract, franchise, or consent with New York City
or one of its agencies? ......................................................................................... Yes
No
If you answered Yes to any of the above, are you engaged in local
transit service? ..................................................................................................... Yes
No
State your average weekly mileage on
State your average weekly mileage under
local transit services routes in New York State ....
contract with school districts in New York State
School district contract:
State all other average weekly mileage
in New York State .................................................
Starts
Ends
Reconciliation
Gallons
A Beginning physical inventory, New York State locations only ............................................................................... A
B Bulk purchases in New York State
................................................................................. B
(from Schedule 1 on back)
C Over-the-road purchases in New York State
.................................................................. C
(from Schedule 2 on back)
D Total
.................................................................................................................................... D
(add lines A, B, and C)
E Closing physical inventory, New York State locations only ...................................................................................
E
F Available for use ..................................................................................................................................................
F
Computation of refund
Gallons
Number of gallons:
1 Used in your buses in New York State from New York State purchases for purposes other than local transit service
1
2 Used in your buses in New York State from New York State purchases for local transit service only ..................
2
3 Taken out-of-state in fuel tanks of buses and consumed out-of-state .................................................................
3
4 Used or sold in any manner other than lines 1, 2, and 3 .....................................................................................
4
5 Loss or gain in bulk tank ......................................................................................................................................
5
6 Total accounted for (must agree with line F above)
........................................................................................
6
Refund claimed on gals. line 1
x $.03 per gal.
Caution: Read this certificate before signing.
I hereby declare that this application has been made with the knowledge that a willfully
Refund claimed on gals. line 2
x $.08 per gal.
false representation is a crime under Section 1812 of the New York State Tax Law
Total refund claimed $
and Sections 175.35 and 210.45 of the Penal Law punishable by fines and penalties
stipulated therein and affirm that the statements contained herein are true.
How was line 3 above arrived at?
County of
Date
Did you complete summary on reverse side? Yes
No
Signature of claimant
Telephone number
Have you attached all invoices?
Yes
No
(
)
Mail refund application to: NYS Tax Department, Fuel Tax
State whether owner or member of firm; or if officer, give title or office
Refund Unit, P O Box 5501, Albany New York 12205-5501

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