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Form AU-741
Department of Revenue Services
Excise Taxes Unit
Received by DRS
25 Sigourney Street
Motor Vehicle Fuels Tax Refund Claim
Hartford CT 06106-5032
2007
Period of Claim in Calendar Year
Commuter Vans
(Rev. 07/07)
____/____ through ____/____
You must check the appropriate fuel type box at right. Refund claims must be filed on or before May 31, 2008,
Connecticut Tax Registration Number
for fuel used during calendar year 2007. Complete this refund claim in blue or black ink only.
Name of Claimant (Print)
FEIN
Telephone Number
SSN
(
)
Number and Street
Fuel Type:
Diesel
Motor Vehicle Fuels
(Gasoline-Gasohol)
City or Town
Claim Type:
Commuter Vans
State
ZIP+4
Type of Business
Location of Records (if different from above)
Owner or Lessee of Vehicle
Vehicle Registration Number
Average Daily Passengers (Minimum 9)
Name of Driver
Employer of Driver
Daily Routes Traveled (Start – Finish – Towns)
Daily Miles Traveled
Schedule A
Statement of Motor Vehicle Fuel Purchases: Receipts must be attached. Attach additional sheet(s) as necessary to provide a complete response.
Date
Name of Supplier
Gallons of Fuel
Date
Name of Supplier
Gallons of Fuel
Total
Round to the nearest whole gallon.
Schedule B
Odometer Readings at the Beginning and the End of Period
1.
Odometer reading at end of a period
1.
2.
Odometer reading at beginning of a period
2.
3.
Total mileage for a period: Subtract Line 2 from Line 1.
3.
Schedule C
Computation of Net Refund
1.
Total miles for period: Enter amount from Schedule B, Line 3.
1.
2.
Total Gallons of Fuel for period: Enter the total Gallons of Fuel from Schedule A.
2.
3.
Average miles per gallon: Divide Line 1 by Line 2 - carry to .0001.
3.
4.
Total miles to and from work for this period
4.
5.
Refund gallons: Divide Line 4 by Line 3.
5.
6.
Tax refund claimed: Multiply Line 5 by _______ per gallon. See Refund Rates on reverse.
6.
$
.00
Declaration: I declare under penalty of law that I have examined this return (including any accompanying schedules and statements) and, to
the best of my knowledge and belief, it is true, complete, and correct. I understand the penalty for willfully delivering a false return or document
to the Department of Revenue Services (DRS) is a fine of not more than $5,000, or imprisonment for not more than five years, or both. The
declaration of a paid preparer other than the taxpayer is based on all information of which the preparer has any knowledge.
Taxpayer Signature
Title
Date
Print Taxpayer Name
Telephone Number
Email Address
(
)
Print Preparer Name
Preparer’s SSN or PTIN
Email Address