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Form Rt-125d - Refund Application Municipal And County - Tax Paid Diesel Only - Nh Department Of Safety Road Toll Bureau - 2005

STATE OF NEW HAMPSHIRE

FOR OFFICIAL USE ONLY

DEPARTMENT OF SAFETY

CLAIM NUMBER:

DIVISION OF ADMINISTRATION

ROAD TOLL BUREAU

CLASS NO.

NO. MOS.

APPROVED

DISALLOWED

33 HAZEN DRIVE

GALS.

CONCORD NH 03305

TELEPHONE: (603) 271-2302

REASON NO.

TDD Access: Relay NH 1-800-735-2964

DATE

ROAD TOLL REFUND APPLICATION

MUNICIPAL AND COUNTY

TAX PAID DIESEL ONLY

CITY, TOWN, SCHOOL DISTRICT, VILLAGE DISTRICT OR COUNTY

DEPARTMENT

(OFFICE ADDRESS) STREET

CITY/TOWN

STATE

ZIP CODE

TELEPHONE NUMBER

This is to certify that the above has purchased diesel upon which the road toll has been paid and the diesel purchased

was subsequently used in motor vehicles owned by the applicant, in accordance with RSA 260:47.

Period of ____________________ yr. __________ through ____________________ yr. __________

APPLICANT’S CLAIM

1. Total gallons, as per attached invoices

Gals.

2. Total gallons consumed:

Gals.

3. Amount of refund (Line 2 X $0.18)

______________

Only photocopies of all purchases bearing name and address of supplier and name of the applicant together

with evidence of payment must be attached. Photocopies of invoices cannot be returned to the applicant.

Evidence of payment: Each invoice must be receipted by the supplier as being paid, or if payment is made by

check, the date of payment and check number must be supplied.

Per SAF-C 310.01 (f): “Motor fuel claimed on the refund application shall be the actual amount of motor fuel used by the

applicant. Application for a refund shall be submitted quarterly by the last day of the first quarter following the last quarter

included in the claim in accordance with RSA 260:47, III (a) which requires the same filing period for refunds as the filing

deadline for federal excise taxes on fuels.”

MINIMUM REFUND IS TEN DOLLARS ($10.00).

Evidence of erasures or changes in either the dates, amounts shown in the invoice or evidence of payment shall

result in the invoice being disallowed.

Signature

Title

"This application is signed under penalty of unsworn falsification pursuant to RSA 641:3."

RT-125D (Rev.07/05)

Form Rt-125d - Refund Application Municipal And County - Tax Paid Diesel Only - Nh Department Of Safety Road Toll Bureau - 2005

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