Looking for a New York State Tax Forms And Templates? Download it for free!

FT-1006

New York State Department of Taxation and Finance

Application for Refund of the New York State

(9/11)

Diesel Motor Fuel Tax by an Omnibus Carrier

Tax Law — Article 12-A, Section 289-c

This form is used by persons or firms operating as omnibus carriers including omnibuses

Do not write in this space

operated under contract with a New York State School District under the Education Law.

Audited and approved for payment

Name of claimant

Business telephone number

Address

City

State

ZIP code

(number and street)

Department of Taxation and Finance

Line 16 gallons

Records kept at

(if different from address above)

x $.01 = $

Line 17 gallons

Federal employer identification number (EIN)

Social security number

NYS sales tax ID number

x $.064 = $

Line 18 gallons

You must complete all lines and the schedules on page 2.

x $.08 = $

1a Total number of buses operated using diesel motor fuel:

Total refunds $

1b Do your buses have New York State motor vehicle license plates? ............

Yes

Audited by:

Date:

2 Do you have a New York State Department of Transportation Certificate

Approved by:

Date:

of Convenience and Necessity ? If Yes, enter the number

Yes

Approved by:

Date:

3 Do you have a United States Department of Transportation Certificate

Do not use this block

of Convenience and Necessity ? If Yes, enter the number

Yes

4 Do you operate pursuant to a contract franchise or consent with the city

of New York or one of its agencies? ........................................................

Yes

5 If you answered Yes to any of the above, are you engaged in local

transit service

? .....................................................

Yes

(see definition on page 2)

6 Enter average weekly mileage on local transit service routes:

7 Enter average weekly mileage under contract with school districts in New York State:

8 Enter all other average weekly mileage:

Inventory and purchases

(New York State locations only)

Number of gallons purchased

with the diesel motor fuel tax

Period covered — From:

to:

included

9 Beginning physical inventory

.................................................................................................................

(gallons)

10 Bulk purchases

.........................................................................................................

(from Schedule A on page 2)

11 Purchases at filling stations

......................................................................................

(from Schedule B on page 2)

12 Total

.................................................................................................................................

(add lines 9, 10, and 11)

13 Closing physical inventory..................................................................................................................................

14 Total gallons available for use

..................................................................................

(subtract line 13 from line 12)

Use

(number of gallons)

15 Gallons of B20 purchased, that were used in your buses in New York State

(from gallons shown on line 14)

for purposes other than local transit service ..................................................................................................

16 Gallons other than the gallons on line 15 used in your buses in New York State

(from gallons shown on line 14)

for purposes other than local transit service

..................................

(enter here and in the gallons box on line 22)

17 Gallons of B20 purchased, that were used in your buses in New York State

(from gallons shown on line 14)

for local transit service only

(enter here and in the gallons box on line 23)

Explain:

18 Gallons other than the gallons on line 17 used in your buses in New York State

(from gallons shown on line 14)

for local transit service only

Explain:

(enter here and in the gallons box on line 24)

19 Gallons taken out of state in fuel tanks of buses and consumed out of state ...................................................

20 Gallons disposed of in any manner other than lines 15, 16, 17, 18, and 19 ......................................................

21 Total gallons accounted for (

........................................................

add lines 15 through 20; must agree with line 14)

Calculation of refund

22 Amount of refund for other than local transit service

x $.01 = ............

gallons

(from line 16)

23 Amount of refund for local transit service

x $.064 = ............

gallons

(from line 17)

24 Amount of refund for local transit service

x $.08 = ............

gallons

(from line 18)

25 Total refund claimed

......................................................................................................

(add lines 22, 23, and 24)

Read this certification before signing. Presenting a fraudulent claim is a crime under New York State Tax Law section 1812 and Penal Law section 210.45 punishable by a fine up to

$10,000 for an individual or $20,000 for a corporation.

I hereby certify that the above claim is just, true, and correct, that no part thereof has been paid, except as stated therein, and that the balance therein stated is actually due and owing.

Signature of claimant

State whether you are an owner or member of firm; or if you are an officer, give title of office. Date

Mail to: NYS TAX DEPARTMENT, FUEL TAX REFUND UNIT, PO BOX 5501, ALBANY NY 12205-5501.