Form Gtr04-Motor Vehicle Fuel (Gasoline) Tax Refund Request July 2000
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2NEVADA DEPARTMENT OF TAXATION
MOTOR VEHICLE FUEL (GASOLINE) TAX REFUND REQUEST
GENERAL
____________________________________________ Refund is claimed for nonhighway use as checked below:
Name of Claimant
(
) Mining
(
) Contracting
____________________________________________
(
) Well Drilling
(
) Railroads
Street Address or P. O. Box Number
____________________________________________
(
) Other_________ Account No.___________________
City
State
Zip Code
INSTRUCTIONS
1. The reverse side of this claim must be filled out from daily fuel use records and must account for all gallonage.
2. Claims for refund must be filed within 6 months of the date of the earliest invoice.
3. The minimum claim allowed is for 200 gallons, purchased and used in a 6 month period.
4. Only customers’ original invoices may be used to substantiate a refund claim except as follows:
5. If the original invoice is lost or destroyed, account for it on this claim but deduct the gallonage on the reverse side.
st
Submit a separate claim covering the duplicate invoice (1
carbon copy) as it must be held for 6 months from the date of
purchase before it may be honored. Under no circumstances will photocopies of invoices be acceptable.
6. Forward this application, properly signed, with original invoices attached, to the Nevada Department of Taxation, 1550 E.
College Parkway Room 115, Carson City, Nevada 89706.
7. Daily records must be maintained and preserved for a period of 3 years for audit purposes.
NUMBER
NUMBER
NUMBER
INVOICE
INVOICE
OF GALLONS
INVOICE
INVOICE
OF GALLONS
INVOICE
INVOICE
OF GALLONS
NUMBER
DATE
PURCHASED
NUMBER
DATE
PURCHASED
NUMBER
DATE
PURCHASED
27 – 32 CENTS
1 CENT
Use whole gallons only
(STATE/COUNTY)
OPTION TAX
Total gallons purchased (Gasoline)
Less gallons for highway use
Total gallons claimed for refund
Rate of refund
.0098
Refund amount
County in which gasoline was TAXED________________________
NOTE: Submit a separate claim for each county in which you purchase fuel for which you are claiming a refund.
I, the undersigned, certify the fuel claimed for refund as stated above, and documented by the attached original invoices, was
purchased and used off highway and the dates shown on the invoices are true and correct, and I am entitled to a refund
under the provisions of NRS 365.
Dated this __________________day of ______________________, ________________
Claimant Signature:____________________________________________
(
) Check here if you need more forms
Area Code/Telephone Number:____________________________________________
Federal Identification or Social Security Number:____________________________________________
-
GTR 04A
07-21-00
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