Form Ft-505 - Claim For Refund Of Taxes Paid On Government Entity Credit Card Purchases Of Fuel

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FT‑505
New York State Department of Taxation and Finance
Claim for Refund of Taxes Paid on Government
(9/11)
Entity Credit Card Purchases of Fuel
Tax Law — Articles 12‑A, 13‑A, 28, and 29
This claim form may only be used by a credit card issuer
.
(see instructions)
For office use only
Total approved
For tax period:
beginning:
ending:
(see instructions)
Employer identification number (EIN)
Telephone number
Audited by
Date
(
)
Legal name
Approved by
Date
Address
Approved by
Date
(number and street)
City
State
ZIP code
‘ Approved by
Date
Column A
Column B
Column C
Computation of refund
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
.................................
3
(add lines 1 and 2, Column B)
4 Petroleum business tax paid (motor fuel) ...............
4
5 Petroleum business tax paid (diesel motor fuel) ....
5
6 Total Article 13‑A refund requested
.................................
6
(add lines 4 and 5, Column B)
7 State and local sales tax (motor fuel) .....................
7
8 State and local sales tax (diesel motor fuel)...........
8
9 Total state and local sales tax refund requested
.................................
9
(add lines 7 and 8, Column B)
10 Total refund requested
(add lines 3, 6 and 9,
10
.............................................................
$
Column C)
Certification:
I, the claimant named above, or partner, officer, or other authorized representative of such applicant, do hereby: make application for
refund, 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
(
)
Firm’s name
Firm’s EIN
Preparer’s PTIN or SSN
Paid
(or yours if self-employed)
preparer
Signature of individual preparing this claim
Address
City
State
ZIP code
use
only
E‑mail address of individual preparing this claim
Telephone number
Preparer’s NYTPRIN
Date
(see instr.)
(
)

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