Form Rdgs - Retail Dealer'S Gasoline Shrinkage Refund Application

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RDGS
Maine Revenue Services
Retail Dealer’s Gasoline Shrinkage
00
Refund Application
*1133000*
Registration No.
Period Begin
Due Date
Period End
1. Entity Information
2.
OUT OF BUSINESS?
Date closed:
3.
OWNERSHIP OR NAME CHANGE?
Date
Explanation
4.
SOLD? Date
ADDRESS CHANGE? Make corrections above and check here
Do Not Use Red Ink!
Please read instructions on reverse side.
Supplier’s Statement
Gallons purchased by retail
Type of Fuel
Applicable
dealer
Tax Collected and Reported
Sold
Tax Rate
(whole gallons only)
,
,
.
,
,
Gasoline
0.300
1.
,
,
.
E10
0.300
2.
,
,
,
,
.
Other
,
,
3.
,
,
.
Other
4.
,
,
,
,
.
Total Tax Paid - Add lines 1-4
5.
,
,
.
Refund Claim - Line 5 X .005
6.
The undersigned states that the above gallonage of gasoline was sold to the above
Mail To:
/
retail dealer for the above period, that payment has been received for such
Maine Revenue Service
P.O. Box 1064
gasoline, and that the undersigned is authorized to make this statement.
Augusta, ME 04332-1064
Date
Name of Supplier
Authorized Signature
This claim is signed under the penalties of perjury.
Date
Signature/Title of Retail Dealer
Printed Name
Phone #
RDGS - Revised 07/2011
For assistance in completing this form, call (207) 624-9609

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