Form 413/nnmft/web - Application For Refund Of Motor Fuel Tax
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1
2Ministry of
Mailing Address:
APPLICATION FOR REFUND
Provincial Revenue
PO Box 9442 Stn Prov Govt
OF MOTOR FUEL TAX
Consumer Taxation Branch
Victoria BC V8W 9V4
pursuant to the Motor Fuel Tax Act and
Nisga’a Nation Taxation Agreement
INSTRUCTIONS:
Mail this form and all required documents to:
• A refund can only be claimed within six years of payment of the tax.
• A claim will not be processed if the required documents/information
Ministry of Provincial Revenue
are not supplied.
Consumer Taxation Branch
PO Box 9442 Stn Prov Govt
• Make a copy of this application and any attachments for your records.
Victoria BC V8W 9V4
• Please complete Parts A, B, C and D. Type or print clearly.
• See reverse for schedule and other information.
Freedom of Information and Protection of Privacy Act
• If you require additional information, call the Consumer Taxation Branch
The personal information requested is collected under
information line in Vancouver at 604 660-4524 or contact your nearest
the authority of and used for the purpose of administering
Consumer Taxation Branch office. Phone numbers for these offices
the Motor Fuel Tax Act . Questions about how the Freedom
of Information and Protection of Privacy Act applies to
are in the blue pages of your local telephone directory.
this personal information can be directed to the Tax
• Consumer Taxation Branch information and bulletins are available on
Analyst (250 356-7342), Consumer Taxation Branch,
PO Box 9442 Stn Prov Govt, Victoria BC V8W 9V4.
the Internet:
CLAIMANT INFORMATION
LEGAL NAME OF NISGA’A GOVERNMENT BODY
MAILING ADDRESS
CITY
PROVINCE
POSTAL CODE
FAX NO.
PHONE NO.
(
)
(
)
– Please check (
) one and provide details
TYPE OF NISGA’A GOVERNMENT BODY
NISGA’A LISIMS GOVERNMENT
P
NISGA’A VILLAGE
A
OTHER NISGA’A BODY (e.g., TRUST)
R
T
ELIGIBLE NISGA’A CORPORATION
DETAILED REFUND INFORMATION
A
1. In support of your refund application, you must
This detail is necessary to ensure that the correct amount
provide copies of all bills of sale, invoices, or
of tax is refunded. The amount of your refund is dependent
receipts showing the names and addresses of
upon the location and time period of the fuel purchase.
the seller, the date of purchase, the litres
PLEASE NOTE:
purchased and the tax paid, as well as any other
A refund can only be paid to the person who actually paid the
documents to support your application.
tax. Therefore, please submit a separate form for each
2. If your claim contains more than one invoice, please
Nisga’a government body. No refund will be made to 3rd
prepare a schedule of all fuel purchases, following
parties acting on behalf of the claimant. Indicate the amount
the format on the reverse of this form.
of provincial motor fuel tax you are applying for. Do not
include the federal goods and services tax (GST) on this
3. Ensure that invoices within each section are listed in
application.
date order.
REFUND AMOUNT
P
A
I am applying for a refund
Total fuel litres subject to refund:
R
of tax in the amount of:
T
$
B
Litres
CLAIMANT DECLARATION
By signing below, I certify that our Nisga’a government body qualifies for a refund of motor fuel tax paid on fuel
purchases listed on the reverse of this application, or attached as part of this application, as provided by the Nisga’a
Nation Taxation Agreement, and that the following criteria have been met.
1. The fuel was purchased or consumed within the Province of British Columbia.
2. The fuel was not acquired for consumption or use in the course of a business or other activity for profit or gain.
P
3. Substantially all of the fuel was consumed or used in respect of performing a function of government, within Nisga’a
A
lands, under the Nisga’a Treaty or a subsequent agreement between Canada and British Columbia, together or
separately, and the Nisga’a Nation.
R
T
Additionally, I certify that if fuel on which a refund has been paid is subsequently used for a purpose that is not eligible
for the refund (i.e., a business purpose), tax will apply to the fuel at the time it is converted to a taxable use.
C
I declare that all information provided on this form and on the attached documents is true and correct to the best of my
knowledge and belief. I acknowledge that any false information may result in prosecution, a fine up to $10,000, and/or
imprisonment for up to two years.
– Please type or print
CLAIMANT NAME
ORGANIZATION POSITION / TITLE
SIGNATURE
DATE SIGNED
YYYY
MM
DD
X
FIN 413/NNMFT/WEB Rev. 2001 / 8 / 16
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