Free Form AU-474 - New York

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