Form Gt-9a - Gasoline Refund Application For Those Engaged In The Business Of Farming Page 2

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Name of vendor from whom gasoline was purchased
Gallons purchased
Street address of vendor
State
Zip
If application includes gasoline used by custom operators on your farm, complete the following:
Name of operator
Street address of operator
State
Zip
List all equipment (registered and unregistered) in which gasoline was used. Itemize gallonage consumed in each piece of equipment (records must
be kept to substantiate total gallonage):
Registration number
Gallons
(farmplate or auto and
Highway use
Non-highway use
Type of equipment
truck license plate number)
Total gallons
Enter on page 1, line 6.
Enter on page 1, line 7.
If more space is needed, attach additional sheets.

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