Form Ft-504 - Claim For Refund Of Taxes Paid On Fuel By A Government Entity printable pdf download

FT‑504

New York State Department of Taxation and Finance

Claim for Refund of Taxes Paid on

(9/11)

Fuel by a Government Entity

Tax Law — Articles 12‑A, 13‑A, 28, and 29

This claim form may only be used for fuel used or consumed by a government entity

(see instructions)

For office use only

Total approved

For tax period:

beginning:

ending:

(see instructions)

Employer identification number (EIN)

Telephone number

Audited by

Date

(

)

Name of government entity

Approved by

Date

Address

Approved by

Date

(number and street)

City

State

ZIP code

‘ Approved by

Date

Column A

Column B

Column C

Computation of refund

Gallons

Tax paid

Totals

(from schedules)

1 Motor fuel excise tax paid ......................................

2 Diesel motor fuel excise tax paid ...........................

3 Total Article 12‑A refund requested

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

(add lines 1 and 2, Column B)

4 Petroleum business tax paid (motor fuel) ...............

5 Petroleum business tax paid (diesel motor fuel) ....

6 Total Article 13‑A refund requested

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

(add lines 4 and 5, Column B)

7 State and local sales tax (motor fuel) .....................

8 State and local sales tax (diesel motor fuel)...........

9 Total state and local sales tax refund requested

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

(add lines 7 and 8, Column B)

10 Total refund requested

(add lines 3, 6 and 9,

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

Column C)

Certification:

I, the claimant named above, or partner, officer, or other authorized representative of such applicant, do hereby: make application for

refund, pursuant to New York State Tax Law; and certify that the above statements, and any documents provided to substantiate the refund claimed, are

true, complete and correct and that no material information has been omitted; and certify that all of the tax for which this claim is filed has been paid, and

no portion has been previously credited or refunded to the applicant by any person required to collect tax; or if the claim for refund is made by a person

required to collect tax, that no amount claimed has previously been subject to a credit or refund; and make these statements with the knowledge that willfully

providing false or fraudulent information with this document with the intent to evade tax may constitute a felony or other crime under New York State Tax Law,

punishable by a substantial fine and a possible jail sentence; and understand that the Tax Department is authorized to investigate the validity of the credit or

refund claimed and the accuracy of any information provided with this claim.

Signature of authorized person

Official title

Authorized

person

E‑mail address of authorized person

Telephone number

Date

(

)

Firm’s name

Firm’s EIN