Form Mfa-20 - Motor Fuels Refund Application

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Division use only — DLN Stamp
Division use only — Date Stamp
Period
Send to:
mm
yyyy
Division of Taxation
For use for all periods January 2011 and after.
PO Box 189
Do not use this form for refunds for taxes paid before January 2011.
Trenton, NJ 08695-0189
Pursuant to NJSA 54:39-101 et seq 01-2011
Motor Fuels Refund Application
MFA-20
Formerly A-3711
Mailing Address of Applicant
Person to contact regarding this application
Applicant Name
Name
Title
Applicant Trade Name
Phone
Email
Applicant FEIN or SSN
Report Whole Gallons Used in This Month Only
Diesel /
Gasoline
Kerosene
Claimant Number
----Do not use MFA-20; use Form A-3766----
Diesel used in passenger vehicles
1
From Division of Taxation
Certain Autobusses
2
Aircraft
3
Tractors & Farm machinery
Tractors & Farm machinery
4
4
Gasoline Refund Requested
Off-road use of On-road vehicles
5
Non-highway equipment - see instructions
6
$
Cleaning
7
Diesel/Kero Refund Requested
Fire engines or fire fighting aparatus
8
Ambulances & First Aide
9
$
Vehicles exclusively on rails
10
Total Refund Amount Requested
Heating and Lighting
11
Motor Boats for BSA or Sea Scouts
12
$
Exports to other states or countries
13
Water craft for approved usage
14
Division use only
Rural Free Delivery
15
Sales to Governmental Entities
16
Approved
Denied
Total Gallons
Reviewed By
Tax Rates
X 0.105
X 0.135
Refund Requested
Signature indicates that, under penalty of perjury, the information presented on this application is
Date:
accurate to the best of the signatory's knowledge. If the information is not accurate or not verifiable,
Amount Approved
the refund may be denied in part or in whole. If a refund is paid in error, or if the application is found to
have error subsequent or contemporaneously to the issuance of the refund, the amount refunded must
$
be repaid to the State along with applicable penalty and interest Incomplete applications cannot be
Refund No
Printed Name
MFA-20
Title
Date
Signature

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