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FT-1007

New York State Department of Taxation and Finance

Application for Refund of Prepaid Sales Tax on

(9/11)

Highway Diesel Motor Fuel Sold at

Retail Service Stations

Print or type

(see instructions)

Name

Certificate of authority number

For office use only

Department of Taxation and Finance

Address

Total

(number and street)

City

State

ZIP code

Telephone number

Audited by

(

)

Name of representative

Telephone number

Approved by

(if any)

(

)

Street address

Date approved

City

State

ZIP code

Office of the State Comptroller

Audited by

Date approved

Period covered by this claim:

From:

To:

Check number

(mm/dd/yyyy)

Sales tax rate at business location

Type of business

(Mark an X in all that apply.)

Motor fuel sales (gasoline)

Highway diesel motor fuel sales

Convenience store

Repairs

Other sales

(explain)

Section 1 — Computation of refund

1 Amount of sales tax due on highway diesel motor fuel sold during period ....................................................

2 Amount of sales tax prepaid to suppliers on highway diesel motor fuel sold during period ...........................

3 Amount eligible for credit or refund

(subtract line 2 from line 1) ...................................................................................

4 Amount on line 3 taken as a credit on any sales tax return

......................................................................................

5 Total refund requested

(subtract line 4 from line 3) .........................................................................................................

Section 2 — Summary of diesel motor fuel purchases

(attach additional sheets if necessary)

Column A

Column B

Column C

Column D

Column E

Column F

Column G

Name of

Date of

Invoice number

Product code

Prepaid sales

Total gallons

Prepaid sales tax

supplier

purchase

tax per gallon

purchased

paid on purchase

(see instructions)

Certification:

I, the claimant named above, or partner, officer, or other authorized representative of such applicant, do hereby: make application for refund of

prepaid sales tax, pursuant to New York State Tax Law; and certify that the above statements, and any documents provided to substantiate the refund claimed,

are true, complete and correct and that no material information has been omitted; and certify that all of the tax for which this claim is filed has been paid, and no

portion has been previously credited or refunded to the applicant by any person required to collect tax; or if the claim for refund is made by a person required

to collect tax, that no amount claimed has previously been subject to a credit or refund; and make these statements with the knowledge that willfully providing

false or fraudulent information with this document with the intent to evade tax may constitute a felony or other crime under New York State Tax Law, punishable

by a substantial fine and a possible jail sentence; and understand that the Tax Department is authorized to investigate the validity of the credit or refund claimed

and the accuracy of any information provided with this claim.

Signature of authorized person

Official title

Authorized

person

E-mail address of authorized person

Telephone number

Date

(

)

Any person who attempts to use this form to evade the tax on diesel motor fuel is liable for penalties as provided by New York State Sales Tax Law and Regulations.

Form Ft-1007 - Application For Refund Of Prepaid Sales Tax On Highway Diesel Motor Fuel Sold At Retail Service Stations

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