Form Au-725b - Motor Vehicle Fuels Tax (Farm Use Only) - Diesel - Claim For Refund
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1STATE OF CONNECTICUT
DEPARTMENT OF REVENUE SERVICES
MOTOR FUEL SECTION
(FARM USE ONLY)
25 Sigourney Street, Hartford CT 06106-5032
INSTRUCTIONS
1. See reverse side for general instructions and information.
2. Mail original to the Department of Revenue Services at the above address.
3. REFUND CLAIMS MUST BE FILED BY MAY 31, 1999 for purchases made during
calendar year 1998.
FOR DEPARTMENT USE ONLY
CT Tax Registration Number / Social Security Number
Telephone Number
Audit Number
(
)
Claim Number
Name of Claimant (Please type or print)
Refund Gallons
Number and Street
City or Town
State
ZIP+4
Refund Tax
$
Reviewed By
Date
Location of Records (if different from above)
Type of Business
Approved By
Date
Prior Claim Filed for Period Ending
Period of Claim
/
/
From
To
No. of Storage Tanks
Meters
Total Capacity
Acres Under Cultivation
Type of Farming
Storage Tanks
Yes
No
Non-taxable
Month
Purchased From
Number of Diesel Gallons
Taxable Use
Use
Beginning Inventory
Ending Inventory
Total Use
Multiply non-taxable use by 18¢ per gallon $ ____________________
(No refund for motor fuel used in these vehicles)
Make
Year
Type
Motor Vehicle Reg. # Make
Year
Type
Motor Vehicle Reg. #
Make
Year
Type
Motor Vehicle Reg. # Make
Year
Type
Motor Vehicle Reg. #
Make and Type
Make and Type
Make and Type
Make and Type
I DECLARE UNDER THE PENALTIES OF FALSE STATEMENT THAT I HAVE EXAMINED THIS CLAIM AND TO THE BEST OF MY KNOWLEDGE
AND BELIEF IT IS TRUE, COMPLETE AND CORRECT.
Signature
Title
Date
Print Name
AU-725b (Rev. 7/98)
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