Free Form AU-630 - New York

AU-630
(4/01)
Legal name DBA (if different from legal name) Street address City

New York State Department of Taxation and Finance

Tax Read the instructions, Form AU-630-I carefully. Employer identification number (or social security number)

Application for Reimbursement of the Petroleum Business Tax
Law Article 13-A ( )
Total

For tax period

to

Business telephone number

Office use only Department of Taxation and Finance

Audited by Approved by

Date approved

Department of Audit and Control
Audited by Date approved

State

ZIP code

Check number

Part I -- Basis for reimbursement (Check one or more boxes. Also, if applicable, check the appropriate box to indicate the type of fuel.) G A retail filling station that sold diesel motor fuel for residential heating purposes in quantities of 10 gallons or less (complete Schedule A). G A retail filling station that sold G motor fuel and/or G diesel motor fuel to governmental entities (complete Schedule B). G A wholesaler/jobber of motor fuel, not registered as a distributor of motor fuel, who sold motor fuel to governmental entities or other G G G G
exempt entities (complete Schedule B). A wholesaler/jobber of motor fuel, not registered as a distributor of motor fuel, who exported motor fuel out of New York State (complete Schedule C). A governmental entity that purchased G diesel motor fuel, G motor fuel or G residual petroleum product for its own use and consumption (complete Schedule D). A passenger commuter ferry operator who used diesel motor fuel or residual petroleum product in a mass transportation service (complete Schedule D). An organization described in section 1116(a)(4) or section 1116(a)(5) of the Tax Law that purchased G unenhanced diesel motor fuel and/or G residual petroleum product for its own use and consumption in a related business activity. The fuel may not be consumed on New York State public highways (complete Schedule D). Enter your exempt organization certificate number . Explain how this fuel was used: A consumer who used G diesel motor fuel and/or G residual petroleum product on or after April 1, 2001, and used the fuel and/or product directly and exclusively in the production of tangible personal property for sale by mining or extracting (complete Schedule D). A consumer, not registered under Articles 12-A or 13-A for the fuel for which the reimbursement is being claimed, who purchased G diesel motor fuel, G motor fuel, or G residual petroleum product, tax included, for his or her own use and consumption and consumed the fuel in a nontaxable manner under Article 13-A (complete Schedule D). Explain how this fuel was used:

G G

Part II -- Computation of reimbursement (Attach any required documentation. See instructions.)
Diesel motor fuel section
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1. Total gallons of diesel motor fuel sold for residential heating purposes (from Schedule A, column d) ........................................................................... 1 · 2. Total gallons of diesel motor fuel sold to governmental entities (from Schedule B, column d) .... 2 · 3. Total gallons of diesel motor fuel purchased by you for which you are 3 · entitled to a reimbursement (from Schedule D, column d) ................................. 4. Add lines 1 through 3 ...................................................................................... 4 · 5. Applicable petroleum business tax per gallon on the diesel motor fuel (see instructions) ..................................... 6. Reimbursement of petroleum business tax on diesel motor fuel (multiply line 4 by line 5) ..................................... Motor fuel section ............................................................................................... 7. Total gallons of motor fuel sold to governmental entities (from Schedule B, column e) ... 7 · 8. Total gallons of motor fuel exported out of New York State (from Schedule C, column d) 8 · 9. Total gallons of motor fuel purchased by you for which you are entitled to a . reimbursement (from Schedule D, column e) ................................................. 9 · 10. Add lines 7 through 9 ...................................................................................... 10 11. Applicable petroleum business tax per gallon on the motor fuel (see instructions) .......... 11 12. Reimbursement of petroleum business tax on motor fuel (multiply line 10 by line 11) ............................................. Residual petroleum product section 13. Total gallons of residual petroleum product purchased by you for which you are entitled to a reimbursement (from Schedule D, column f) ........................... 13 · 14. Applicable petroleum business tax per gallon on the residual petroleum product (see instructions) .................. 15. Reimbursement of petroleum business tax on residual petroleum product (multiply line 13 by the rate on line 14) ......... Total reimbursement section 16. Total reimbursement requested (add lines 6, 12, and 15) ..............................................................................................

5 6

12

14 15 16

Page 2 AU-630 (4/01) Schedule A ­ Diesel motor fuel purchased with the petroleum business tax included and sold for residential heating a Date of sale b Purchaser's name c Purchaser's address d Number of gallons of diesel motor fuel

Total gallons (total the gallons in column d; enter here and on line 1) ............................................................ Enter on line 1

Schedule B ­ Diesel motor fuel and motor fuel purchased with the petroleum business tax included and sold to governmental entities a Date of sale b Governmental entity c Contract/approval number d Number of gallons of diesel motor fuel e Number of gallons of motor fuel

Total gallons (total each of the gallons columns; enter here and on line 2 or 7) .................. Enter on line 2 Enter on line 7

AU-630 (4/01) Page 3 Schedule C ­ Motor fuel purchased with the petroleum business tax included and exported out of New York State a Date of sale b Purchaser's name c Purchaser's address d Number of gallons of motor fuel

Total gallons (total the gallons in column d; enter here and on line 8) ...................................................................... Enter on line 8

Page 4 AU-630 (4/01) Schedule D ­ Purchases of diesel motor fuel, motor fuel, and residual petroleum product on which your supplier included the petroleum business tax and for which you are entitled to a reimbursement
a Date of purchase b Seller's name and FEIN or social security number c Seller's address d Number of gallons of diesel motor fuel e Number of gallons of motor fuel f Number of gallons of residual petroleum product

Total gallons (total each of the gallons columns;
enter here and on lines 3, 9, or 13) ...............................................................................

Enter on line 3

Enter on line 9

Enter on line 13

Certification: I, the claimant, or an officer or authorized representative of the claimant, do hereby make application for reimbursement of the petroleum business tax pursuant to New York State Tax Law, and certify that to the best of my knowledge all New York State petroleum business taxes for which this claim has been filed have been paid; no portion of the tax has been reimbursed or credited to me by any vendor; and no items for which reimbursement or credit was previously claimed or received are included. I make these statements with the knowledge that willfully issuing a document known to be false or fraudulent as to any material matter is a misdemeanor under section 1812-f(c)(2) of the New York State Tax Law and section 210.45 of the Penal Law, punishable by a fine up to $10,000 for an individual or $20,000 for a corporation.
Signature Print name Title Date

Mail to: NYS TAX DEPARTMENT, FUEL TAX REFUND UNIT, PO BOX 5501, ALBANY NY 12205