Employeridentificationnumber
Application for Refund of the Petroleum Business Tax Because of a Bad Debt
Tax Law - Article 13-A, Section 301-I
Telephonenumber
AU-474
(9/06)
ReadinstructionsAU-474-Ibeforecompletingthisform. ( )
Forofficeuseonly Totalapproved Auditedby Approvedby Approvedby Date Date Date
Legalname
DBA(ifdifferentthanabove)
Streetaddress City,stateandZIPcode
1 Registration(checkallthatapply)
Distributorofdieselmotorfuel Residualpetroleumproductbusiness
Distributorofmotorfuel Retailerofheatingoilonly to
2 Federaltaxreturnonwhichthebaddebtwasclaimed: Typeoffederalreturn(formnumber) 3 PetroleumBusinessTax(PBT)ScheduleofBadDebts
A Dateof Sale B AccountName C TaxReturn Period
Periodcoveredbythereturn
D Typeof Product
(completeworksheetbelow forpartialpayments)
E UnpaidAmount
F PBTRate perGal.
G PBTIncludedin UnpaidAmount
TotalPBTBadDebtRefund(addcolumnGamounts) Worksheet for Partial Payments (completethisworksheetifpaymentsweremadeontheaccount)
AccountName AccountName AccountName
(a) Sellingprice(notincludingfinancecharges)................... .
(b) PBTincludedinthesellingprice ................................. . (c) PercentageofPBT(divide(b)by(a))............................. (d) Partialpaymentmadeonsale..................................... (e) AmountofpartialpaymentappliedtoPBT(multiply(c)by(d)) (f) PBTallowedasbaddebtrefund(subtract(e)from(b)).... Transfer each row (f) amount to column G of Schedule of Bad Debts above
Certification: IcertifythatallNewYorkStateArticle13-Ataxes,forwhichthisclaimisfiled,havebeenpaidbymeandthisisa true,correctandcompletereport.
Signature
Paid Preparer's Preparer'ssignature Firm'sname(oryours,ifself-employed) Address Date Title EINorsocialsecuritynumber Date Telephonenumber
( )
Use Only
ZIPcode
Powerofattorneyattached? Yes No
Mailto:NYS TAX DEPARTMENT, FUEL TAX REFUND UNIT, PO BOX 5501, ALBANY NY 12205-0501