Form Pdr-1t - Transit And Ambulance Claim For Refund

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PDR-1T
Transit and Ambulance Claim for Refund
You must use the most current version of this form. Forms are available at
Check if filing:
Original claim; or
Amended claim
Company Name
Minnesota Tax ID
Address
Period (enter month and year)
City
State
ZIP Code
Under which of the following Minnesota statutes are you filing (check one)?
M.S. 174.24. Contracted to and receiving financial assistance from the Minnesota Department of Transportation.
M.S. 473.384. Contracted to and receiving financial assistance from the Metropolitan Council.
M.S. 256B.0625, subd. 17. Registered with and receiving reimbursement for medical transportation from the Minnesota Department
of Human Services. Enter provider #:
M.S. 144E.10. Licensed with the Emergency Medical Ground Services Regulatory Board.
M.S. 144E.12. Licensed with the Emergency Medical Air Services Regulatory Board.
M.S. 296A.07 Subd. 4 (2)/296A.08 Subd. 3 (2) Transportation providers (see instructions for details).
M.S. 296A.07 Subd. 4 (4)/296A.08 Subd. 3 (4) Mobile medical labs (see instructions for details).
A
B
C
D
Gasoline
Undyed Diesel/
AV Gas
Jet Fuel
Undyed Kerosene
(round to whole gallons)
(round to whole gallons) (round to whole gallons)
(round to whole gallons)
1 Gallons (see instructions on back for
.00
.00
.00
.00
method of calculating refund) . . . . . . . . . 1
0 .
0 .
0 .05
.15
2 Tax rate (determine from instructions) . 2
$
$
$
$
3 Multiply line 1 by line 2 . . . . . . . . . . . . . . 3
4 Gasoline and special fuel tax refund (add line 3, columns A, B, C and D) . . . . . . . . . . . . . . 4$
For a direct deposit refund, complete the following (see instructions on back). Otherwise, you will receive a check.
Account type:
Routing number
Account number
Checking
Savings
Attach a detailed list of all qualifying vehicles and equipment.
You must keep all records regarding this refund (receipts, mileage logs, bills of lading, fuel logs, transportation reimbursement requests
from other agencies, etc.) for at least 3½ years.
All refunds are subject to audit by the Department of Revenue.
I declare under the penalties of criminal liability for willfully making any false statements herein, that this refund claim has been
examined by me and to the best of my knowledge and belief is true and complete.
Authorized Signature
Title
Date
Daytime Phone
Mail Form PDR-1T and your list of qualifying vehicles to:
Minnesota Revenue, Petroleum Taxes, Mail Station 4108, St. Paul, MN 55146-4108.
Phone: 651-296-0889
Email: petroleum.tax@state.mn.us
(Rev. 8/17)

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