Form 72a053-A - Application For Refund Of Kentucky Motor Fuel Tax Paid On Nonhighway Motor Fuels (Krs 138.344 Through 138.355)
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1
2FOR DEPARTMENT USE ONLY
APPLICATION FOR REFUND
72A053-A (7-07)
Date
Commonwealth of Kentucky
OF KENTUCKY MOTOR FUEL TAX PAID
Processed ______________ By
/
/
_______________
DEPARTMENT OF REVENUE
ON NONHIGHWAY MOTOR FUELS
(KRS 138.344 through 138.355)
➤ ➤ ➤ ➤ ➤ See Instructions on Reverse
Name of
Kentucky Motor Fuels Tax
Applicant ________________________________________________
Refund Permit Number __________________________
Mailing
Federal Employer
Address __________________________________________________
__ __ –__ __ __ __ __ __ __
ID Number
_________________________________________________________
Refund claim is being filed:
City
State
ZIP Code
For calendar quarter ending ____________________
(
)
Telephone Number ________________________________________
For calendar year ending December 31, _____
Agricultural
Special
PART I—Computation of Refund Gallonage
Gasoline
Fuels
1. Kentucky tax-paid motor fuel gallons reflected on attached refund invoices ......................
gal.
gal.
2. Number of line 1 gallons used in unlicensed vehicles on the highways ...............................
gal.
gal.
3. a. Number of gallons of gasoline used in stationary engines or tractors
for agricultural purposes (line 1 minus line 2) .......................................................................
gal.
b. Number of gallons of special fuels used in unlicensed vehicles or
equipment for nonhighway purposes (line 1 minus line 2) .................................................
gal.
PART II—Computation of Kentucky Sales Tax to be Deducted from Special Fuels Tax Refund
Kentucky Sales Tax Permit Number _______________
NOTE: If you claim that the special fuel reported on line 3 above is exempt from the 6 percent Kentucky
sales tax, indicate the reason below and do not complete the remainder of Part II. Proceed to Part III.
I hold an Energy Direct Pay Authorization.
Fuel used for agricultural purposes pursuant to KRS 139.480.
Other (describe) ________________________________________________________________________
______________________________________________________________________________________
4. Total purchase price (including all taxes paid) of all refund special fuels reflected on attached refund invoices ........
$
5. Deductions:
a. Purchase price (including all taxes you paid) of gallons reported on line 2 above .........................................................
$
b. Kentucky special fuels tax paid on gallons reported on line 3 above (Kentucky tax rate (.____) times gallons) ......
$
c. Kentucky Petroleum Environmental Assurance Fee paid on gallons reported on line 3 above
(.014 times gallons) ......................................................................................................................................................................
$
d. Total deduction (add lines 5a, 5b and 5c) ................................................................................................................................
$
6. Amount subject to Kentucky sales tax (line 4 minus line 5d) ..................................................................................................
$
7. Kentucky sales tax rate ...................................................................................................................................................................
.06
8. Total Kentucky sales tax due (to be deducted from refund) (line 6 times line 7) .................................................................
$
PART III—Motor Fuels Refund Computation
9. Total gallons subject to Kentucky motor fuels tax refund (same as line 3 above) ..................
gal.
gal.
10. Gross motor fuels tax refund claimed (line 9 times Tax Rate) ....................................................
$
$
11. Sales tax liability (same as line 8 above) .........................................................................................
$ (
)
12. Net motor fuels tax refund claimed (line 10 minus line 11) ........................................................
$
$
PART IV—Petroleum Environmental Assurance Fee Refund Computation
13. Total gallons subject to Petroleum Environmental Assurance Fee
(same as line 9 above) ........................................................................................................................
gal.
gal.
14. Fee refund claimed (line 13 gallons times .014) .............................................................................
$
$
Kentucky Department of Revenue
IMPORTANT NOTICE ➤ ➤ ➤ ➤ ➤ Mail completed application to:
Motor Fuels Tax Compliance Section
P.O. Box 1303, Station 63
Frankfort, KY 40602-1303
I hereby certify that this requested refund of Kentucky motor fuels tax is supported by correct and unaltered refund invoices issued by a
licensed motor fuels dealer for motor fuel purchases, that the motor fuel for which refund is claimed herein was placed in a tank marked
"Refund Motor Fuel," and that all information contained herein is true to the best of my knowledge and belief. I further certify that none of
the fuel for which refund is claimed was or will be used in licensed vehicles on public highways.
______________________________________________________________
Date ______________________________________ , 20 ______
Signature of Refund Permit Holder or Authorized Representative
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