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- LP 60211 to d~ <br />4. Contact Information S4k- (k8a L( ( a C622- - LA -5 Aga".-. V°tt VA6AeV0.&-4L1 SkRAlR, cr-bid <br />TELEPHONE INCLUDE AREA CODE FAX NUMBER INCLUDE AREA CODE E-MAIL ADDRESS <br />5. Claim Period: t ®aI o TO a2-t I 1® Date of last Claim: RIMISA L°Aola r <br />FUEL PURCHASED, USED AND STORED: (Round to nearest whole gallon) <br />6. Beginning Inventory on Hand (ending inventory from prior claim) --a- <br />7. Add Fuel Purchased this Period (attach original invoices for purchases) Ag I A16 <br />8. Total Fuel to Account For (line 6 + line 7) LAS L9 <br />9. Deduct Inventory on Hand at end of Period (beginning inventory for next claim period) <br />10. Deduct Fuel used in a non refundable manner <br />11. Total Fuel deductions (line 9 + line 10) 1, 74 <br />!s CXo <br />12. Total Refundable Fuel Used (line 8 - line 11) 33 2 11 <br />13. Amount Claimed for Refund (line 12 x $0.05 per gallon) 1 lr r q A Q . "'Lo- <br />INDICATE TYPE(S) OF REFUNDABLE USAGE BELOW, PROVIDING DETAIL ON THE BACK AS REQUIRED GALLONS <br />14. NON VEHICULAR ENGINES/EQUIPMENT AND UNLICENSED VEHICLES (Total from section 2 Line 1) <br />15. LICENSED VEHICLE USE ON PRIVATE PROPERTY farm and non farm use (Total from section-2 Line 2) <br />16. COMMERCIAL MOTOR BOAT USE: Describe use <br />Boat or Vessel reg # AND Commercial or Charter license # <br />17. OTHER REFUNDABLE USE (Total from section 2 Line 3) <br />18. EXPORTED IN VEHICLE TANK attach proof of tax paid to another state <br />19. GOVERNMENTAL AGENCY USE _ (5 <br />20. TOTAL REFUNDABLE USE (add lines 14 through 19, should equal line 12 above) 3A. to a tt> <br />SECTION 1: FUEL STORAGE (must be complete for all claims) <br />1. How do you acqffizk fuel (check all that apply) <br />MCardlock Retail Other (please explain): <br />2. How do you store your fuel: (Complete if you maintain any storage) Use: On road, off 3. Do you maintain separate <br />Tank (list by name or number) Contents (fuel type) road or both storage for your refundable <br />V:-" tn.g--- , d and nonrefundable use? <br />X? gluon "t -013iRykiab 9-12j-:N- `F-Si6 Ces ALA If rtkth <br />~No <br />I additional space is needed, please attach a separate sheet. <br />Form continued on other side.. <br />SOCIAL SECURITY OR EIN NUMBER <br />J::~~ IA-1 140 2- <br />STATE ZIP CODE <br />sell fuel to others? t" <br />By signing below, I hereby certify that 1 have full knowledge of this claim, that the fuel was purchased on the dates and in the amounts shown on each invoice; that the fuel has been <br />use <br />by claimant in the manner set forth above and that none of the fuel on which a tax refund is claimed was used for operating or propelling motor vehicles upon. any state highway, county <br />road, city street, or upon any other highway, except as authorized by ORS 319; and that no part of the tax refund claimed has been paid. <br />PERSON OTHER THAN CLAIMANT PREPARING CLAIM _ CLAIMANT <br />SIGNATURE <br />PRINT NAME <br />ADDRESS <br />PHONE NUMBER <br />Codes: county <br />state Federal <br />CLAIMANT SIGNA <br />PRINT NAME <br />DATE <br />TITLE <br />Remarks <br />Approved for Payment: Director, Dept of Transportation, by <br />Page 1 of 2 <br />MAIL : L-1 <br />ODOT FUELS TAX GROUP FUELS TAX REFUND CLAIM <br />550 CAPITOL ST NE <br />SALEM OR 97301-2530 CITY OF EUGENE <br />PHONE: (503) 378-8150° <br />