Form Au-629 - Application For Refund/reimbursement Of Taxes Paid On Fuel Sold To Governmental Entities By Registered Distributors
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4AU-629
New York State Department of Taxation and Finance
Application for Refund/Reimbursement of Taxes
(4/11)
Paid on Fuel Sold to Governmental Entities by
Registered Distributors
Tax Law — Articles 12-A, 13-A, 28, and 29
Employer identification or social security number
Business telephone number
For tax period:
(
)
Beginning
Ending
Legal name
For office use onl
y
DBA (if different from legal name)
Total approved
Street address
Audited by
Date
Approved by
Date
City, state, and ZIP code
Column A
Column B
Column C
Computation of reimbursement
Gallons
Tax paid
Totals
(from schedules)
(from schedules)
1 Motor fuel excise tax paid ...............................
1.
2 Diesel motor fuel excise tax paid ....................
2.
3 Total Article 12-A refund requested
(add lines 1 and 2, Column B; enter here and on
......
3.
Form PT-100-B for the same calendar month)
4 Petroleum business tax
..................
4.
(motor fuel)
5 Petroleum business tax
........
5.
(diesel motor fuel)
6 Total Article 13-A refund/reimbursement
requested
(add lines 4 and 5, Column B; enter
here and on Form PT-100-B for the same
.................................................
6.
calendar month)
7 Prepaid sales tax
7.
............................
(motor fuel)
8 Prepaid sales tax
..................
8.
(diesel motor fuel)
9 Total prepaid sales tax refund requested
(add lines 7 and 8, Column B; enter here and on
Form FT-945/1045 for the same calendar month
.....................
9.
and deduct from the credit claimed)
10 Total refund requested
(add lines 3, 6 and 9,
...................................................
10.
Column C)
Certification: I certify that this is a true, correct, and complete report.
Signature
Title
Date
Preparer’s signature
Date
Preparer’s NYTPRIN
Preparer’s SSN or PTIN
Mark
Paid
an X if
preparer
self-employed
use
Preparer’s firm name
(or yours, if self-employed)
Firm’s EIN
E-mail
only
Address
Telephone number
(
)
Mail to: NYS TAX DEPARTMENT, FUEL TAX REFUND UNIT, PO BOX 5501, ALBANY NY 12205-0501
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