Form 72a078 - Statement Of Claim For Accountable Loss Of Motor Fuel printable pdf download

72A078 (4-11)

STATEMENT OF CLAIM FOR

Submit in Triplicate

Commonwealth of Kentucky

Please type or print.

ACCOUNTABLE LOSS OF MOTOR FUEL

DEPARTMENT OF REVENUE

Claim must be filed within 30 days from date of loss.

Gasoline Dealer’s

Special Fuels Dealer’s

Name and Address of Dealer

License Number

GL—_______________

FL—_______________

(

)

Phone Number ___________________________________________

Number of Gasoline

Number of Special

Gallons Claimed

Fuels Gallons Claimed

Contact Person ___________________________________________

___________________

NOTE: Please see reverse side for instructions before completing the items below.

1. Provide exact date of loss.__________________________________________________________________________________

2. From what type of storage was the motor fuel lost?

Transport Truck

Bulk Plant

Service Station

Other ________________________________________

3. Where did the loss occur?__________________________________________________________________________________

4. What method was used to determine the amount of loss?__________________________________________________________

______________________________________________________________________________________________________

5. What evidence is available to support loss?____________________________________________________________________

6. Indicate the size of storage tank(s) in gallons.__________________________________________________________________

7. If loss resulted from contamination, indicate number of gallons of motor fuel contaminated and returned to terminal storage.

_________________________ Terminal storage operator name and address of terminal. ________________________________

______________________________________________________________________________________________________

8. Indicate the type of loss (fire, flood, etc.), and briefly describe how the loss occurred.___________________________________

______________________________________________________________________________________________________

I, the undersigned, a principal officer of the above-named licensee have examined this claim and it is, to the best of my knowledge and

belief, a true, correct and valid claim.

__________________________________

_______________________

_____________________

__________________

Signature of Claimant

Print Name

Title

Date

Mail claim completed in triplicate with documentation to the Department of Revenue, Motor Fuels Tax Compliance Section, P.O. Box 1303, Frankfort, KY 40602-1303.

FOR DEPARTMENT USE ONLY

Gasoline Gallons Approved .............................................................................................................................................................

(Attach copy to 72A089. Claim this amount on Line 9.)

Special Fuels Gallons Approved .....................................................................................................................................................

(Attach copy to 72A138. Claim this amount on Line 8.)

________________________________________________

___________________________

Signature

Date