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FT-950

New York State Department of Taxation and Finance

Application for Refund of Prepaid Sales Tax on

(9/11)

Motor Fuel Sold at Retail Service Stations

(See instructions on page 2 of this form)

Print or type

Name

Certificate of Authority number

For office use only

Department of Taxation and Finance

Street address

Total

City

State

ZIP code

Telephone number

Audited by

(

)

Approved by

Name of representative

Telephone number

(if any)

(

)

Street address

Date approved

City

State

ZIP code

Office of the State Comptroller

Audited by

Date approved

Period covered by this claim:

From:

To:

Check number

(mm/dd/yyyy)

Sales tax rate at business location

Type of business —

(mark an X in all that apply)

Motor fuel sales (gasoline)

Highway diesel motor fuel sales

Convenience store

Repairs

Other sales

(explain)

Section 1 — Computation of refund

1 Amount of sales tax due on motor fuel sold during period ............................................................................

2 Amount of sales tax prepaid to suppliers on motor fuel sold during period ..................................................

3 Amount eligible for credit or refund

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

(subtract line 2 from line 1)

4 Amount on line 3 taken as a credit on any sales tax return............................................................................

5 Amount of refund claimed

(subtract line 4 from line 3) ..................................................................................................

Section 2 — Summary of motor fuel purchases

(attach additional sheets if necessary)

Column A

Column B

Column C

Column D

Column E

Column F

Column G

Name of

Date of purchase Invoice number

Type of fuel

Prepaid sales tax

Total gallons

Prepaid sales tax

supplier

U for unleaded

per gallon

purchased

paid on purchase

P for premium

Certification:

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

of prepaid sales tax, 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 the 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 or 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

Preparer’s PTIN or SSN

Paid

(or yours if self-employed)

preparer

Signature of individual preparing this return

Address

City

State

ZIP code

use

only

E-mail address of individual preparing this return

Telephone number

Preparer’s NYTPRIN

Date

(see instr.)

(

)

Any person who attempts to use this form to evade the tax on motor fuel is liable for penalties as provided by the New York State Sales Tax Law and Regulations.

Form Ft-950 - Application For Refund Of Prepaid Sales Tax On Motor Fuel Sold At Retail Service Stations

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