Form Au-741 - Motor Vehicle Fuels Tax Refund Claim - 2009
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Form AU-741
Department of Revenue Services
State of Connecticut
Received by DRS
Excise Taxes Unit
Motor Vehicle Fuels Tax Refund Claim
25 Sigourney St Ste 2
2009
Commuter Vans
Period of claim in calendar year
Hartford CT 06106-5032
(Rev. 09/09)
____/____ through ____/____
You must check the appropriate fuel type box at right. Refund claims must be filed on or before May 31, 2010,
Connecticut Tax Registration Number
for fuel used during calendar year 2009. Complete this refund claim in blue or black ink only.
Federal Employer Identification Number (FEIN)
Print name of claimant
Telephone number
Social Security Number (SSN)
(
)
Number and street
Fuel type:
Diesel
Motor vehicle fuels
(gasoline-gasohol)
City or town
Claim type:
Commuter vans
State
ZIP code
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.
A qualifying vehicle is a vehicle which meets the average daily passenger minimum of nine.
Schedule B
Odometer Readings at The Beginning and The End of Period
1.
Odometer reading at end of a period for qualifying vehicles
1.
2.
Odometer reading at beginning of a period for qualifying vehicles
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 for qualifying vehicles
2.
3.
Average miles per gallon: Divide Line 1 by Line 2; carry to .0001.
3.
4.
Total Connecticut 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’s name
Telephone number
Email address
(
)
Print preparer’s name
Preparer’s SSN or PTIN
Email address
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