Form Dr 7118 - Fuel Tax Refund Claim

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Department Use Only
DR 7118 (05/24/11)
COLORADO DEPARTMENT OF REVENUE
DENVER, CO 80261-0009
(303) 205-8205
FUEL TAX REFUND CLAIM
Audit Date
Time Limit Date
No. of Invoices Earliest Date
If above address is not correct please call (303) 205-8205
Latest Date
7118-650
Colorado Permit/Account Number
Refund Period
FEIN or Social Security Number
C
D
E
A
B
WHOLE GALLONS ONLY — NO DECIMALS
Special Fuel
Aviation Gas
Aviation Fuel
Gasoline
Gasohol
(Diesel, Etc.)
•
1. Total number of gallons of qualifying fuel
purchased in Colorado.
See General Information I on reverse side.
2. Approved refund percentage decimal
3. Net number of gallons of fuel purchased in
Colorado for which refund is being claimed.
(Line 1 multiplied by line 2, for every fuel type)
Line 3
Line 3
Line 3
Line 3
Line 3
multiplied by
multiplied by
multiplied by
multiplied by
multiplied by
4. Colorado Fuel Excise Tax Rate per gallon.
cents
cents
cents
cents
cents
5. Amount of Refund Claim
Multiply line 3 by Tax Rate line 4.
Total amount of refund claim. (Add together lines 5A thru 5E)
$
Type:
Checking
Savings
Routing number
Account number
I certify and declare that this application is true and correct and that it is made under the penalties of perjury in the second degree.
Name of Claimant, Corporation or Partnership
Signature of Claimant
Signature of Witness
Date
Telephone
See reverse side for instructions on completing this form

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