Form Ft-400/401 - Application For Reimbursement Of Nys Petroleum Business Tax (Pbt) On Motor Fuel/diesel Motor Fuel For An Omnibus Carrier-Nonpublic School Operator
ADVERTISEMENT
1
2FT-400/401
New York State Department of Taxation and Finance
Application for Reimbursement of NYS Petroleum
(11/09)
Business Tax (PBT) on Motor Fuel/Diesel Motor Fuel for an
Omnibus Carrier/Nonpublic School Operator
Tax Law — Article 13-A, Section 301-c
Print or type
For office use only
Period covered (mm/dd/yy) — From:
To:
Legal name of claimant
Business telephone number
(
)
Motor fuel gallons
Reimbursement
Address
City
State
ZIP code
(number and street)
Line 16
$
Line 17
$
Records kept at
(if different from address above)
Line 18
$
Federal employer identification number (EIN)
Social security number
NYS sales tax ID number
Diesel motor fuel gallons
Line 16
$
You must complete all lines and schedules on the back.
(Mark an X in the appropriate box below.)
Line 17
$
1 Total number of buses operated using motor fuel ......................................
Line 18
$
1a Total number of buses operated using diesel motor fuel .............................
2 Do your buses have New York State motor vehicle license plates? ............
Yes
No
Total reimbursement
$
3 Do you have certification from the New York State Department of
Transportation (NYSDOT) ? If Yes, enter the number
Yes
No
Audited by
Date
4 Do you have federal certification from the United States Department of
Transportation (USDOT) ? If Yes, enter the number
Yes
No
Approved by
Date
5 Do you operate pursuant to a contract, franchise, or consent with
New York City or one of its agencies? ......................................................
Yes
No
Approved by
Date
6 If you answered Yes to any of the above, are you engaged in local
transit service
? .................................................................
Yes
No
(see instructions)
Approved by
Date
7 Enter average weekly mileage on local transit service routes .....................
8 Enter average weekly mileage under contract with school districts in New York State
9 Enter all other average weekly mileage .......................................................
Column A
Column B
Inventory and purchases
(New York State locations only)
Motor fuel gallons
Diesel motor fuel gallons
(from schedules)
(from schedules)
10 Beginning physical inventory
........................................................................... 10.
(gallons)
11 Bulk purchases
................................................................... 11.
(from Schedule A on page 2)
12 Purchases at filling stations
................................................ 12.
(from Schedule B on page 2)
13 Total
......................................................................................... 13.
(add lines 10, 11, and 12)
14 Closing physical inventory............................................................................................ 14.
15 Total gallons available for use
............................................ 15.
(subtract line 14 from line 13)
Use —
Enter the number of gallons that were used in your buses in New York State.
16 Local transit service ..................................................................................................... 16.
17 Transportation of school children under contract with school districts ....................... 17.
18 Nonpublic school operators engaged in education-related activities .......................... 18.
19 Reimbursable gallons
........... 19.
(add lines 16, 17, and 18; enter here and on line 23 or line 24)
20 Gallons taken out of state in fuel tanks of buses and consumed out of state ............. 20.
21 All other uses within New York State............................................................................ 21.
22 Total gallons (
............................................................................. 22.
add lines 19, 20, and 21)
Calculation of reimbursement
gallons
Motor fuel PBT rate of
×
23 Motor fuel reimbursement
= .... 23.
tax shown on invoice(s)
(from line 19)
gallons
Diesel motor fuel PBT rate
24 Diesel motor fuel reimbursement
= .... 24.
×
of tax shown on invoice(s)
(from line 19)
25 Total reimbursement
............................................................................................................ 25.
(add lines 23 and 24)
Certification: I certify that all New York State Article 13-A taxes, for which this claim is filed, have been paid and included in the purchase price paid by me
and that no portion of these taxes have been refunded or credited to me previously. I make these statements with the knowledge that knowingly presenting a
fraudulent claim is a crime under New York State Tax Law section 1812-f and Penal Law section 210.45 punishable by fines and penalties stipulated therein.
Print name
Official title
Signature of claimant
Date
Mail to: NYS TAX DEPARTMENT, FUEL TAX REFUND UNIT, PO BOX 5501, ALBANY NY 12205-0501.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial