Department of Revenue Services
Form AU-737
Reset Form
Excise Taxes Unit
Fuel Type
Motor Vehicle Fuels Tax Refund Claim
25 Sigourney Street
Diesel
Motor Vehicle Fuels
Hartford CT 06106-5032
Airport Service (Motor Bus)
(Gasoline - Gasohol)
Claim Type
You must check the appropriate fuel type box on the right. Refund claims
(Rev. 07/06)
must be filed on or before May 31, 2007, for fuel used during calendar year
Airport Service (Motor Bus)
2006. Complete this refund claim in blue or black ink only.
For DRS Use Only
Name of Claimant (Type or print)
Period of Claim in Calendar Year
Audit Number
2006
____/____ through ____/____
Claim Number
Voucher Number
Telephone Number
CT Tax Registration Number
(
)
Refund Gallons
Number and Street
FEIN
City or Town
SSN
Refund
$
State
ZIP+4
Due On or Before
May 31, 2007
Reviewed By
Date
Type of Business
Location of Records (if different from above)
Approved By
Date
Schedule A
Statement of Motor Vehicle Fuel Purchases. Receipts must be attached.
Date
Name of Supplier
Gallons of Fuel
Date
Name of Supplier
Gallons of Fuel
Total
(Round to the nearest whole gallon.)
Motor bus companies must attach a copy of their certificate of public convenience and necessity issued under Chapter 244 of the
Connecticut General Statutes with each claim filed.
Schedule B
Computation of net refund
1.
Total miles for period
1.
2.
Total fuel gallons for period (Enter the total number of fuel gallons from Schedule A.)
2.
3.
Average miles per gallon (Divide Line 1 by Line 2.)
3.
4.
Total Connecticut miles used for transportation of passengers to or from airport facilities
4.
5.
Refund gallons (Divide Line 4 by Line 3.)
5.
.00
6.
Tax refund claimed
6. $
(Multiply Line 5 by _____ per gallon. See refund rate table on reverse side for appropriate rate.)
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 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
Date
Print Preparer Name
Preparer’s Address
Preparer’s SSN or PTIN